"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" 100|DRG||SEIZURES W MCC|Managed Medicaid|MEDICAID SUPERIOR|55,210.15|19405.15|19405.15|2127.76|||| 100|DRG||SEIZURES W MCC|Blue Cross HMO Specialty|BCBSTX HMO|55,106.75|2127.76|19405.15|2127.76|||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||684.50||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||684.50||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|United Healthcare|UNITED HEALTHCARE OTHER|||||684.50||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|Managed Medicaid|MEDICAID AMERIGROUP|||||684.50||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|Medicare|MEDICARE ACUTE|684.50||||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|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||684.50||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|Humana Medicare Advantage|HUMANA MA|||||684.50||| 10060|EAP|0450|I&D ABCESS SIMP/SNGL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||684.50||| 10061|EAP|0450|I&D ABSCESS COMP/MULTIPLE|Medicare|MEDICARE ACUTE|||||1,043.50||| 10080|EAP|0450|I&D PILONIDAL CYST SIMPLE|Blue Cross PPO Specialty|BCBSTX PPO|||||513.50||| 101|DRG||SEIZURES W/O MCC|Humana Medicare Advantage|HUMANA MA|60,271.25|8823.25|8940.45|7910.71|||| 101|DRG||SEIZURES W/O MCC|Medicare|MEDICARE ACUTE|31,988.50|8940.45|8940.45|7910.71|||| 101|DRG||SEIZURES W/O MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|15,247.75|7910.71|8940.45|7910.71|||| 10120|EAP|0450|REM FB SUBQ SIMPLE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,161.75||| 10120|EAP|0450|REM FB SUBQ SIMPLE|Blue Cross PPO Specialty|BCBSTX PPO|||||1,161.75||| 10120|EAP|0450|REM FB SUBQ SIMPLE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1,161.75||| 10160|EAP|0450|ASP ABSCESS/HEMA/BUCCA/CY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||513.50||| 10160|EAP|0450|ASP ABSCESS/HEMA/BUCCA/CY|Managed Medicaid|MEDICAID AMERIGROUP|||||513.50||| 10160|EAP|0450|ASP ABSCESS/HEMA/BUCCA/CY|Managed Medicaid|MEDICAID SUPERIOR|||||513.50||| 10160|EAP|0450|ASP ABSCESS/HEMA/BUCCA/CY|Blue Cross PPO Specialty|BCBSTX PPO|||||513.50||| 10160|EAP|0450|ASP ABSCESS/HEMA/BUCCA/CY|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||513.50||| 10160|EAP|0450|ASP ABSCESS/HEMA/BUCCA/CY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|513.50||||||| 11730|EAP|0450|AVULSION NAIL PLATE SMPLE|NON CONTRACTED|COMMERCIAL OTHER 1|||||2.85||| 11740|EAP|0450|EVAL SUBUNGUAL HEMATOMA|Humana Medicare Advantage|HUMANA MA|||||2.26||| 11750|EAP|0450|RMV NAIL BED|Managed Medicaid|MEDICAID SUPERIOR|||||13.93||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Managed Medicaid|MEDICAID SUPERIOR|||||647.50||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Blue Cross HMO Specialty|BCBSTX HMO|||||647.50||| 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.|Medicaid|MEDICAID PCCM|||||647.50||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|647.50||||647.50||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|United Healthcare|UNITED HEALTHCARE OTHER|||||647.50||| 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.|Managed Medicaid|MEDICAID AMERIGROUP|||||647.50||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Workers Compensation|UT EMPLOYEE INJURY|||||647.50||| 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.|Medicare|MEDICARE ACUTE|||||647.50||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||647.50||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Humana Medicare Advantage|HUMANA MA|||||647.50||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||647.50||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|NON CONTRACTED|COMMERCIAL OTHER 1|||||647.50||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||647.50||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||647.50||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||647.50||| 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|||||647.50||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Cigna|CIGNA|||||647.50||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||647.50||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Medicaid|MEDICAID|647.50||||647.50||| 12001|EAP|0450|RPR SCLP/NCK/TRUNK/EXT 2.|Medicaid|MEDICAID TEXAS CHILDRENS|||||647.50||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Cigna|CIGNA|||||408.50||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Veterans Affairs|VETERANS ADMINISTRATION|||||408.50||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||408.50||| 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|United Medicare Advantage|UHC MEDICARE GOLD MA|||||408.50||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||408.50||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||408.50||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||408.50||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Aetna|AETNA PPO|||||408.50||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Workers Compensation|WORKERS COMPENSATION OTHER|||||408.50||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Blue Cross PPO Specialty|BCBSTX PPO|408.50||||408.50||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Medicare|MEDICARE ACUTE|408.50||||408.50||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Managed Medicaid|MEDICAID AMERIGROUP|||||408.50||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||408.50||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Medicaid|MEDICAID PCCM|||||408.50||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Managed Medicaid|MEDICAID SUPERIOR|||||408.50||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Humana Medicare Advantage|HUMANA MA|||||408.50||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Medicaid|MEDICAID|||||408.50||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||408.50||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||408.50||| 12002|EAP|0450|RPR LAC SIMPL 2.6-5CM|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||408.50||| 12004|EAP|0450|RPR LAC SIMPL 7.6-12.5CM|Medicaid|MEDICAID|||||452.50||| 12004|EAP|0450|RPR LAC SIMPL 7.6-12.5CM|Blue Cross PPO Specialty|BCBSTX PPO|||||452.50||| 12004|EAP|0450|RPR LAC SIMPL 7.6-12.5CM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||452.50||| 12004|EAP|0450|RPR LAC SIMPL 7.6-12.5CM|Veterans Affairs|VETERANS ADMINISTRATION|||||452.50||| 12004|EAP|0450|RPR LAC SIMPL 7.6-12.5CM|Managed Medicaid|MEDICAID AMERIGROUP|||||452.50||| 12004|EAP|0450|RPR LAC SIMPL 7.6-12.5CM|Medicare|MEDICARE ACUTE|||||452.50||| 12004|EAP|0450|RPR LAC SIMPL 7.6-12.5CM|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||452.50||| 12005|EAP|0450|RPR LAC SIMPL 12.6-20CM|Managed Medicaid|MEDICAID SUPERIOR|||||832.25||| 12005|EAP|0450|RPR LAC SIMPL 12.6-20CM|Medicare|MEDICARE ACUTE|||||832.25||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Blue Cross HMO Specialty|BCBSTX HMO|||||5.96||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Blue Cross PPO Specialty|BCBSTX PPO|||||5.96||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||5.96||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||5.96||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Aetna|AETNA PPO|||||5.96||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Medicaid|MEDICAID|||||5.96||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||5.96||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Medicare|MEDICARE ACUTE|5.96||||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|Managed Medicaid|MEDICAID AMERIGROUP|||||5.96||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||5.96||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Managed Medicaid|MEDICAID SUPERIOR|||||5.96||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|PHCS|HUMANA INSURANCE|||||5.96||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||5.96||| 12011|EAP|0450|RPR LAC SIMPL FACE 2.5CM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||5.96||| 12013|EAP|0450|RPR LAC SIMPL FACE 2.6-5.|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||624.75||| 12013|EAP|0450|RPR LAC SIMPL FACE 2.6-5.|Medicare|MEDICARE ACUTE|||||624.75||| 12013|EAP|0450|RPR LAC SIMPL FACE 2.6-5.|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||624.75||| 12013|EAP|0450|RPR LAC SIMPL FACE 2.6-5.|Managed Medicaid|MEDICAID AMERIGROUP|||||624.75||| 12013|EAP|0450|RPR LAC SIMPL FACE 2.6-5.|Blue Cross HMO Specialty|BCBSTX HMO|||||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.|Aetna|AETNA PPO|||||624.75||| 12013|EAP|0450|RPR LAC SIMPL FACE 2.6-5.|Workers Compensation|WORKERS COMPENSATION OTHER|||||624.75||| 12013|EAP|0450|RPR LAC SIMPL FACE 2.6-5.|Blue Cross PPO Specialty|BCBSTX PPO|||||624.75||| 12013|EAP|0450|RPR LAC SIMPL FACE 2.6-5.|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||624.75||| 12013|EAP|0450|RPR LAC SIMPL FACE 2.6-5.|United Healthcare|UNITED HEALTHCARE|||||624.75||| 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||| 12015|EAP|0450|RPR LAC SIMPL FACE 7.6-12|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||832.25||| 12016|EAP|0450|RPR LAC SIMPL FACE 12.6-2|Medicare|MEDICARE ACUTE|||||495.75||| 12031|EAP|0450|RPR LAYER CLOSURE 2.5CM O|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||556.25||| 12031|EAP|0450|RPR LAYER CLOSURE 2.5CM O|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||556.25||| 12031|EAP|0450|RPR LAYER CLOSURE 2.5CM O|Aetna|AETNA OTHER|||||556.25||| 12034|EAP|0450|RPR LAYER CLOSURE 7.6-12.|United Healthcare|UNITED HEALTHCARE|||||762.25||| 12034|EAP|0450|RPR LAYER CLOSURE 7.6-12.|Humana Medicare Advantage|HUMANA MA|||||762.25||| 12034|EAP|0450|RPR LAYER CLOSURE 7.6-12.|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||762.25||| 12052|EAP|0450|RPR LAYER CLOS FACE 2.6-5|Medicare|MEDICARE ACUTE|||||832.25||| 149|DRG||DYSEQUILIBRIUM|Medicare|MEDICARE ACUTE|53,927.45|7902.06|7902.06|7902.06|||| 153|DRG||OTITIS MEDIA & URI W/O MCC|Managed Medicaid|MEDICAID SUPERIOR|8,504.75|5006.15|5010.9|2948.99|||| 153|DRG||OTITIS MEDIA & URI W/O MCC|Medicaid|MEDICAID|9,838.50|5010.9|5010.9|2948.99|||| 153|DRG||OTITIS MEDIA & URI W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|356.89|2948.99|5010.9|2948.99|||| 16000|EAP|0450|TX BURN 1ST DEGREE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||250.75||| 16020|EAP|0450|DEBRIDE BURN PART THICK <|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||606.75||| 16020|EAP|0450|DEBRIDE BURN PART THICK <|Managed Medicaid|MEDICAID SUPERIOR|||||606.75||| 16020|EAP|0450|DEBRIDE BURN PART THICK <|Managed Medicaid|MEDICAID AMERIGROUP|||||606.75||| 16020|EAP|0361|BURN DRESS/DEBRIDE SMALL|Managed Medicaid|MEDICAID AMERIGROUP|||||5.56||| 16020|EAP|0450|DEBRIDE BURN PART THICK <|Blue Cross PPO Specialty|BCBSTX PPO|||||606.75||| 17250|EAP|0361|CHEMICAL CAUTERIZATION PR|Medicare|MEDICARE ACUTE|||||360.50||| 175|DRG||PULMONARY EMBOLISM W MCC OR ACUTE COR PULMONALE|Blue Cross HMO Specialty|BCBSTX HMO|22,378.50|5159.38|24525.45|5159.38|||| 175|DRG||PULMONARY EMBOLISM W MCC OR ACUTE COR PULMONALE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|65,626.05|12542.42|24525.45|5159.38|||| 175|DRG||PULMONARY EMBOLISM W MCC OR ACUTE COR PULMONALE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|45,733.50|11836.89|24525.45|5159.38|||| 175|DRG||PULMONARY EMBOLISM W MCC OR ACUTE COR PULMONALE|Cigna|CIGNA|66,025.75|24525.45|24525.45|5159.38|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Medicaid|MEDICAID|66,440.75|9622.21|43592.42|1385.55|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|United Healthcare|UNITED HEALTHCARE|46,048.40|18894.98|43592.42|1385.55|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Rusk State Hospital|RUSK STATE HOSP|39,655.83|19431.355|43592.42|1385.55|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Blue Cross HMO Specialty|BCBSTX HMO|89,560.25||||||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Managed Medicare|HEALTHSPRING MA|11,587.50|12845.19|43592.42|1385.55|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Blue Cross PPO Specialty|BCBSTX PPO|104,352.50|3813.215|43592.42|1385.55|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|69,057.80|30566.14|43592.42|1385.55|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|64,409.25|18211.03|43592.42|1385.55|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Humana Medicare Advantage|HUMANA MA|49,997.16|17581.38|43592.42|1385.55|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Workers Compensation|WORKERS COMPENSATION OTHER|142,323.70|26041.77|43592.42|1385.55|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|31,016.25|30566.14|43592.42|1385.55|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|86,076.17|20032.13|43592.42|1385.55|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Medicare|MEDICARE ACUTE|61,826.10|18205.78|43592.42|1385.55|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Medicaid|COUNTY INDIGENT HEALTH OTHER|84,825.17|19223.99|43592.42|1385.55|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|NON CONTRACTED|COMMERCIAL OTHER 1|23,434.25|1385.55|43592.42|1385.55|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|60,408.22|18211.03|43592.42|1385.55|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|United Medicare Advantage|AARP UHC WEST COMPLETE MA|28,785.25|12845.19|43592.42|1385.55|||| 177|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC|Workers Compensation|UT EMPLOYEE INJURY|288,972.40|43592.42|43592.42|1385.55|||| 178|DRG||RESPIRATORY INFECTIONS & INFLAMMATIONS W CC|Medicare|MEDICARE ACUTE|25,086.03|11721.59|11721.59|11721.59|||| 180|DRG||RESPIRATORY NEOPLASMS W MCC|Managed Medicare|HOSPICE OF EAST TEXAS|8,003.50|14416.04|14416.04|2644.15|||| 180|DRG||RESPIRATORY NEOPLASMS W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|58,731.47|2644.15|14416.04|2644.15|||| 189|DRG||PULMONARY EDEMA & RESPIRATORY FAILURE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|34,132.25|11210.86|24075.255|10986.64|||| 189|DRG||PULMONARY EDEMA & RESPIRATORY FAILURE|Medicare|MEDICARE ACUTE|96,608.50|11012.05|24075.255|10986.64|||| 189|DRG||PULMONARY EDEMA & RESPIRATORY FAILURE|United Medicare Advantage|UHC MEDICARE GOLD MA|79,085.25|11210.86|24075.255|10986.64|||| 189|DRG||PULMONARY EDEMA & RESPIRATORY FAILURE|Humana Medicare Advantage|HUMANA MA|83,408.81|11065.42|24075.255|10986.64|||| 189|DRG||PULMONARY EDEMA & RESPIRATORY FAILURE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|65,659.43|11000.72|24075.255|10986.64|||| 189|DRG||PULMONARY EDEMA & RESPIRATORY FAILURE|Aenta Medicare Advantage|AETNA MEDICARE MA|48,813.25|10986.64|24075.255|10986.64|||| 189|DRG||PULMONARY EDEMA & RESPIRATORY FAILURE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|28,945.25|24075.255|24075.255|10986.64|||| 189|DRG||PULMONARY EDEMA & RESPIRATORY FAILURE|Managed Medicaid|MEDICAID AMERIGROUP|54,470.50|20394.76|24075.255|10986.64|||| 189|DRG||PULMONARY EDEMA & RESPIRATORY FAILURE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|51,539.38|20394.76|24075.255|10986.64|||| 190|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC|Humana Medicare Advantage|HUMANA MA|44,950.25|10578.53|18232.65|2999.95|||| 190|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC|Blue Cross HMO Specialty|BCBSTX HMO|30,569.75|4193.65|18232.65|2999.95|||| 190|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC|Aetna|AETNA OTHER|111,692.30|10507.7|18232.65|2999.95|||| 190|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC|Blue Cross PPO Specialty|BCBSTX PPO|43,390.50|2999.95|18232.65|2999.95|||| 190|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC|Rusk State Hospital|RUSK STATE HOSP|37,209.50|18232.65|18232.65|2999.95|||| 190|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|51,705.25|10507.7|18232.65|2999.95|||| 190|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|54,737.85|10534.98|18232.65|2999.95|||| 190|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC|Medicare|MEDICARE ACUTE|33,289.75|10532.38|18232.65|2999.95|||| 19000|EAP|0400|US GUIDED BREAST CYST ASP|United Healthcare|UNITED HEALTHCARE OTHER|||||12.31||| 19083|EAP|0402|US BREAST BX RT 1ST LESIO|Managed Medicare|HEALTHSPRING MA|||||2,271.25||| 19083|EAP|0402|US BREAST BX RT 1ST LESIO|Humana Medicare Advantage|HUMANA MA|||||2,271.25||| 19083|EAP|0402|US BREAST BX RT 1ST LESIO|NON CONTRACTED|COMMERCIAL OTHER 1|||||2,271.25||| 19083|EAP|0402|US BREAST BX RT 1ST LESIO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||2,271.25||| 19083|EAP|0402|US BREAST BX RT 1ST LESIO|Blue Cross PPO Specialty|BCBSTX PPO|||||2,271.25||| 19083|EAP|0402|US BREAST BX LT 1ST LESIO|Medicare|MEDICARE ACUTE|||||2,271.25||| 19083|EAP|0402|US BREAST BX LT 1ST LESIO|Humana Medicare Advantage|HUMANA MA|||||2,271.25||| 19083|EAP|0402|US BREAST BX RT 1ST LESIO|Medicare|MEDICARE ACUTE|||||2,271.25||| 19083|EAP|0402|US BREAST BX LT 1ST LESIO|Blue Cross PPO Specialty|BCBSTX PPO|||||2,271.25||| 191|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W CC|Medicare|MEDICARE ACUTE|40,353.75|9007.91|9007.91|8863.76|||| 191|DRG||CHRONIC OBSTRUCTIVE PULMONARY DISEASE W CC|Humana Medicare Advantage|HUMANA MA|34,706.75|8863.76|9007.91|8863.76|||| 193|DRG||SIMPLE PNEUMONIA & PLEURISY W MCC|Veterans Affairs|VETERANS ADMINISTRATION|97,662.50|11800.77|209130.705|6218.8|||| 193|DRG||SIMPLE PNEUMONIA & PLEURISY W MCC|Blue Cross PPO Specialty|BCBSTX PPO|81,289.75|6218.8|209130.705|6218.8|||| 193|DRG||SIMPLE PNEUMONIA & PLEURISY W MCC|NON CONTRACTED|COMMERCIAL OTHER 1|209,130.71|209130.705|209130.705|6218.8|||| 193|DRG||SIMPLE PNEUMONIA & PLEURISY W MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|95,514.56|11779.6|209130.705|6218.8|||| 193|DRG||SIMPLE PNEUMONIA & PLEURISY W MCC|Medicaid|MEDICAID|71,160.75|12012.415|209130.705|6218.8|||| 193|DRG||SIMPLE PNEUMONIA & PLEURISY W MCC|Medicare|MEDICARE ACUTE|47,874.55|11797.76|209130.705|6218.8|||| 193|DRG||SIMPLE PNEUMONIA & PLEURISY W MCC|United Medicare Advantage|AARP UHC WEST COMPLETE MA|93,302.90|11801.65|209130.705|6218.8|||| 193|DRG||SIMPLE PNEUMONIA & PLEURISY W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|52,388.85|41226.97|209130.705|6218.8|||| 193|DRG||SIMPLE PNEUMONIA & PLEURISY W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|117,622.75|11773.49|209130.705|6218.8|||| 193|DRG||SIMPLE PNEUMONIA & PLEURISY W MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|71,993.30|11773.49|209130.705|6218.8|||| 193|DRG||SIMPLE PNEUMONIA & PLEURISY W MCC|Humana Medicare Advantage|HUMANA MA|59,817.20|11856.76|209130.705|6218.8|||| 193|DRG||SIMPLE PNEUMONIA & PLEURISY W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|59,665.50|11801.65|209130.705|6218.8|||| 194|DRG||SIMPLE PNEUMONIA & PLEURISY W CC|Medicare|MEDICARE ACUTE|43,679.08|8903.145|12380.03|8829.88|||| 194|DRG||SIMPLE PNEUMONIA & PLEURISY W CC|Managed Medicaid|MEDICAID SUPERIOR|32,008.83|12380.03|12380.03|8829.88|||| 194|DRG||SIMPLE PNEUMONIA & PLEURISY W CC|Humana Medicare Advantage|HUMANA MA|54,624.10|8845.55|12380.03|8829.88|||| 194|DRG||SIMPLE PNEUMONIA & PLEURISY W CC|United Medicare Advantage|AARP UHC WEST COMPLETE MA|59,975.25|8829.88|12380.03|8829.88|||| 194|DRG||SIMPLE PNEUMONIA & PLEURISY W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|20,096.75|12380.03|12380.03|8829.88|||| 195|DRG||SIMPLE PNEUMONIA & PLEURISY W/O CC/MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|54,678.05|11773.49|12432.63|4881.99|||| 195|DRG||SIMPLE PNEUMONIA & PLEURISY W/O CC/MCC|Medicare|MEDICARE ACUTE|21,425.50|7448.98|12432.63|4881.99|||| 195|DRG||SIMPLE PNEUMONIA & PLEURISY W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|45,461.75|7598.77|12432.63|4881.99|||| 195|DRG||SIMPLE PNEUMONIA & PLEURISY W/O CC/MCC|Medicaid|MEDICAID|44,813.75|4881.99|12432.63|4881.99|||| 195|DRG||SIMPLE PNEUMONIA & PLEURISY W/O CC/MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|37,820.65|12432.63|12432.63|4881.99|||| 196|DRG||INTERSTITIAL LUNG DISEASE W MCC|Medicare|MEDICARE ACUTE|403.64|14080.73|14080.73|14080.73|||| 199|DRG||PNEUMOTHORAX W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|156,575.25|14876.13|14876.13|14876.13|||| 202|DRG||BRONCHITIS & ASTHMA W CC/MCC|Managed Medicaid|MEDICAID SUPERIOR|28,602.75|9138.94|16182.43|3575.2|||| 202|DRG||BRONCHITIS & ASTHMA W CC/MCC|United Healthcare|UNITED HEALTHCARE|24,196.25|9471.47|16182.43|3575.2|||| 202|DRG||BRONCHITIS & ASTHMA W CC/MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|16,033.50|8589.85|16182.43|3575.2|||| 202|DRG||BRONCHITIS & ASTHMA W CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|66,039.15|3575.2|16182.43|3575.2|||| 202|DRG||BRONCHITIS & ASTHMA W CC/MCC|Managed Medicaid|MEDICAID AMERIGROUP|34,610.15|16182.43|16182.43|3575.2|||| 203|DRG||BRONCHITIS & ASTHMA W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|22,861.25|11824.26|11824.26|31.5|||| 203|DRG||BRONCHITIS & ASTHMA W/O CC/MCC|Cigna|CIGNA|147.74|31.5|11824.26|31.5|||| 203|DRG||BRONCHITIS & ASTHMA W/O CC/MCC|Managed Medicaid|MEDICAID AMERIGROUP|18,021.95|6578.515|11824.26|31.5|||| 203|DRG||BRONCHITIS & ASTHMA W/O CC/MCC|Medicare|MEDICARE ACUTE|32,275.62|7527.12|11824.26|31.5|||| 203|DRG||BRONCHITIS & ASTHMA W/O CC/MCC|Medicaid|MEDICAID|32,052.50|5747.76|11824.26|31.5|||| 203|DRG||BRONCHITIS & ASTHMA W/O CC/MCC|Managed Medicaid|MEDICAID SUPERIOR|27,556.50|7660.655|11824.26|31.5|||| 203|DRG||BRONCHITIS & ASTHMA W/O CC/MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|29,653.50|6974.66|11824.26|31.5|||| 203|DRG||BRONCHITIS & ASTHMA W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|44,114.75|2887.67|11824.26|31.5|||| 205|DRG||OTHER RESPIRATORY SYSTEM DIAGNOSES W MCC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|156,098.25|13809.33|13809.33|13809.33|||| 207|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT >96 HOURS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|297,800.20|45627.19|93943.85|45627.19|||| 207|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT >96 HOURS|UTMB|UTMB CORRECTIONAL MANAGED CARE|278,184.89|54800.68|93943.85|45627.19|||| 207|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT >96 HOURS|Rusk State Hospital|RUSK STATE HOSP|191,722.15|93943.85|93943.85|45627.19|||| 207|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT >96 HOURS|Medicare|MEDICARE ACUTE|516,771.95|73261.26|93943.85|45627.19|||| 208|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <=96 HOURS|UTMB|UTMB CORRECTIONAL MANAGED CARE|126,325.65|25303.68|45947.075|19582.89|||| 208|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <=96 HOURS|Medicare|MEDICARE ACUTE|138,303.03|19651.955|45947.075|19582.89|||| 208|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <=96 HOURS|Humana Medicare Advantage|HUMANA MA|111,767.73|19582.89|45947.075|19582.89|||| 208|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <=96 HOURS|Rusk State Hospital|RUSK STATE HOSP|93,769.55|45947.075|45947.075|19582.89|||| 208|DRG||RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <=96 HOURS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|179,296.21|43074.64|45947.075|19582.89|||| 23350|EAP|0322|INJECTION SHOULDER ARTHRO|Blue Cross HMO Specialty|BCBSTX HMO|||||408.50||| 23350|EAP|0322|INJECTION SHOULDER ARTHRO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||408.50||| 23350|EAP|0322|INJECTION SHOULDER ARTHRO|Medicare|MEDICARE ACUTE|||||408.50||| 23350|EAP|0322|INJECTION SHOULDER ARTHRO|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||408.50||| 23350|EAP|0322|INJECTION SHOULDER ARTHRO|Humana Medicare Advantage|HUMANA MA|||||408.50||| 23650|EAP|0450|TX DISLOC SHLDR W MANIP W|Humana Medicare Advantage|HUMANA MA|||||637.25||| 23650|EAP|0450|TX DISLOC SHLDR W MANIP W|Blue Cross PPO Specialty|BCBSTX PPO|||||637.25||| 23650|EAP|0450|TX DISLOC SHLDR W MANIP W|Workers Compensation|WORKERS COMPENSATION OTHER|||||637.25||| 23650|EAP|0450|TX DISLOC SHLDR W MANIP W|United Healthcare|UNITED HEALTHCARE OTHER|||||637.25||| 252|DRG||OTHER VASCULAR PROCEDURES W MCC|Blue Cross HMO Specialty|BCBSTX HMO|33,948.30|11481.02|11481.02|11481.02|||| 25605|EAP|0450|TX FX RADIUS ULNA W MANIP|Blue Cross PPO Specialty|BCBSTX PPO|||||1,185.75||| 26770|EAP|0450|CLSD TRT FINGER JOINT DIS|Rusk State Hospital|RUSK STATE HOSP|||||2.80||| 26770|EAP|0450|CLSD TRT FINGER JOINT DIS|Blue Cross PPO Specialty|BCBSTX PPO|||||2.80||| 27818|EAP|0450|TRT ANKLE DISCOLATION|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.89||||||| 280|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W MCC|Medicare|MEDICARE ACUTE|34,703.75|13756.31|14138.49|137.6|||| 280|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|157,484.42|14138.49|14138.49|137.6|||| 280|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|99,358.92|137.6|14138.49|137.6|||| 280|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W MCC|Medicare|MEDICARE PART B ONLY IP|63,791.75|11495.06|14138.49|137.6|||| 280|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W MCC|Humana Medicare Advantage|HUMANA MA|105,628.50|13854.59|14138.49|137.6|||| 281|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W CC|Medicare|MEDICARE ACUTE|38,989.25|9361.84|9361.84|9361.84|||| 282|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W/O CC/MCC|Medicare|MEDICARE ACUTE|49,162.20|7821.59|7829.69|7821.59|||| 282|DRG||ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|24,359.30|7829.69|7829.69|7821.59|||| 283|DRG||ACUTE MYOCARDIAL INFARCTION, EXPIRED W MCC|Medicare|MEDICARE ACUTE|87,089.06|14883.46|47620.4|14883.46|||| 283|DRG||ACUTE MYOCARDIAL INFARCTION, EXPIRED W MCC|Medicaid|MEDICAID|53,469.75|31990.28|47620.4|14883.46|||| 283|DRG||ACUTE MYOCARDIAL INFARCTION, EXPIRED W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|495,764.36|47620.4|47620.4|14883.46|||| 291|DRG||HEART FAILURE & SHOCK W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|132,472.85|25974.76|25974.76|6065.28|||| 291|DRG||HEART FAILURE & SHOCK W MCC|NON CONTRACTED|COMMERCIAL OTHER 1|44,647.38|17703.34|25974.76|6065.28|||| 291|DRG||HEART FAILURE & SHOCK W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|31,243.30|11883.81|25974.76|6065.28|||| 291|DRG||HEART FAILURE & SHOCK W MCC|Humana Medicare Advantage|HUMANA MA|43,604.90|11913.83|25974.76|6065.28|||| 291|DRG||HEART FAILURE & SHOCK W MCC|Blue Cross PPO Specialty|BCBSTX OTHER|168,266.25|6065.28|25974.76|6065.28|||| 291|DRG||HEART FAILURE & SHOCK W MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|34,935.28|11855.65|25974.76|6065.28|||| 291|DRG||HEART FAILURE & SHOCK W MCC|Medicare|MEDICARE ACUTE|37,415.78|11870.73|25974.76|6065.28|||| 29105|EAP|0450|APPLY LONG ARM SPLINT|Medicare|MEDICARE ACUTE|||||5.96||| 29105|EAP|0450|APPLY LONG ARM SPLINT|Humana Medicare Advantage|HUMANA MA|||||5.96||| 29105|EAP|0450|APPLY LONG ARM SPLINT|Managed Medicaid|MEDICAID SUPERIOR|||||5.96||| 29105|EAP|0450|APPLY LONG ARM SPLINT|Medicaid|MEDICAID|||||5.96||| 29105|EAP|0450|APPLY LONG ARM SPLINT|Managed Medicaid|MEDICAID AMERIGROUP|||||5.96||| 29105|EAP|0450|APPLY LONG ARM SPLINT|United Healthcare|UNITED HEALTHCARE|||||5.96||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|United Medicare Advantage|UHC MEDICARE GOLD MA|||||4.65||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Blue Cross PPO Specialty|BCBSTX OTHER|||||4.65||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Blue Cross HMO Specialty|BCBSTX HMO|||||4.65||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|United Healthcare|UNITED HEALTHCARE|||||4.65||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Blue Cross PPO Specialty|BCBSTX PPO|||||4.65||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Managed Medicaid|MEDICAID AMERIGROUP|4.65||||4.65||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Rusk State Hospital|RUSK STATE HOSP|||||4.65||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Medicare|MEDICARE ACUTE|4.65||||4.65||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Humana Medicare Advantage|HUMANA MA|||||4.65||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|NON CONTRACTED|COMMERCIAL OTHER 1|4.65||||4.65||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||4.65||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Managed Medicaid|MEDICAID SUPERIOR|||||4.65||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||4.65||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Medicaid|MEDICAID|||||4.65||| 29125|EAP|0450|APPLY FOREARM SPLINT STAT|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||4.65||| 292|DRG||HEART FAILURE & SHOCK W CC|NON CONTRACTED|COMMERCIAL OTHER 1|78,302.50|78302.5|78302.5|952.68|||| 292|DRG||HEART FAILURE & SHOCK W CC|Humana Medicare Advantage|HUMANA MA|31,724.75|8581.77|78302.5|952.68|||| 292|DRG||HEART FAILURE & SHOCK W CC|Medicare|MEDICARE ACUTE|51,076.90|8926.63|78302.5|952.68|||| 292|DRG||HEART FAILURE & SHOCK W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|50,234.25|8941.88|78302.5|952.68|||| 292|DRG||HEART FAILURE & SHOCK W CC|Blue Cross PPO Specialty|BCBSTX OTHER|43,546.25|952.68|78302.5|952.68|||| 293|DRG||HEART FAILURE & SHOCK W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|38,717.50|7269.36|7269.36|7269.36|||| 29505|EAP|0450|APPLY LONG LEG SPLINT|Medicaid|MEDICAID|||||332.75||| 29505|EAP|0450|APPLY LONG LEG SPLINT|Managed Medicaid|MEDICAID SUPERIOR|||||332.75||| 29515|EAP|0450|ANKLE AIR STIRRUP/CAST|Managed Medicaid|MEDICAID SUPERIOR|||||2.18||| 29515|EAP|0450|ANKLE AIR STIRRUP/CAST|Humana Medicare Advantage|HUMANA MA|2.18||||||| 29515|EAP|0450|ANKLE AIR STIRRUP/CAST|Managed Medicaid|MEDICAID AMERIGROUP|||||2.18||| 29515|EAP|0450|ANKLE AIR STIRRUP/CAST|Blue Cross PPO Specialty|BCBSTX PPO|||||2.18||| 29515|EAP|0450|ANKLE AIR STIRRUP/CAST|Medicare|MEDICARE ACUTE|||||2.18||| 299|DRG||PERIPHERAL VASCULAR DISORDERS W MCC|Humana Medicare Advantage|HUMANA MA|73,082.05|12637.35|12637.35|12637.35|||| 30300|EAP|0450|REM FB INTRANASAL|Managed Medicaid|MEDICAID SUPERIOR|||||575.75||| 308|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W MCC|Medicare|MEDICARE ACUTE|39,471.25|10243.895|10243.895|10243.895|||| 309|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC|United Medicare Advantage|AARP UHC WEST COMPLETE MA|44,406.95|8079.59|8739.81|7944.44|||| 309|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC|UTMB|UTMB CORRECTIONAL MANAGED CARE|20,583.25|8739.81|8739.81|7944.44|||| 309|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC|Medicare|MEDICARE ACUTE|32,775.35|7944.44|8739.81|7944.44|||| 30903|EAP|0450|CONTROL NOSEBLEED ANT COM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||462.50||| 310|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|277.18|6630.27|6630.27|6628.13|||| 310|DRG||CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC|Medicare|MEDICARE ACUTE|19,436.34|6628.13|6630.27|6628.13|||| 312|DRG||SYNCOPE & COLLAPSE|Humana Medicare Advantage|HUMANA MA|42,399.50|8520.43|8520.43|8520.43|||| 313|DRG||CHEST PAIN|UTMB|UTMB CORRECTIONAL MANAGED CARE|39,281.75|8439.53|8439.53|7670.68|||| 313|DRG||CHEST PAIN|Medicare|MEDICARE ACUTE|33,921.50|7670.68|8439.53|7670.68|||| 31500|EAP|0450|INTUBATION EMERGENCY|Managed Medicaid|MEDICAID SUPERIOR|1,147.50||||1,147.50||| 31500|EAP|0450|INTUBATION EMERGENCY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,147.50||||1,147.50||| 31500|EAP|0450|INTUBATION EMERGENCY|Workers Compensation|WORKERS COMPENSATION OTHER|||||1,147.50||| 31500|EAP|0450|INTUBATION EMERGENCY|Blue Cross HMO Specialty|BCBSTX HMO|||||1,147.50||| 31500|EAP|0450|INTUBATION EMERGENCY|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1,147.50||| 31500|EAP|0450|INTUBATION EMERGENCY|Medicaid|MEDICAID|1,147.50||||1,147.50||| 31500|EAP|0450|INTUBATION EMERGENCY|Rusk State Hospital|RUSK STATE HOSP|||||1,147.50||| 31500|EAP|0450|INTUBATION EMERGENCY|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||1,147.50||| 31500|EAP|0450|INTUBATION EMERGENCY|Humana Medicare Advantage|HUMANA MA|1,147.50||||1,147.50||| 31500|EAP|0450|INTUBATION EMERGENCY|Medicare|MEDICARE ACUTE|1,147.50||||1,147.50||| 31502|EAP|0450|CHANGE TRACH TUBE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|739.50||||||| 31622|EAP|0450|BRONCHOSCOPY DX W/WO FLUR|Medicare|MEDICARE ACUTE|1,292.25||||||| 31622|EAP|0450|BRONCHOSCOPY DX W/WO FLUR|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1,292.25||| 31622|EAP|0450|BRONCHOSCOPY DX W/WO FLUR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,292.25||||||| 31622|EAP|0450|BRONCHOSCOPY DX W/WO FLUR|Blue Cross PPO Specialty|BCBSTX PPO|1,292.25||||||| 32551|EAP|0450|TUBE THORACOSTOMY|United Medicare Advantage|UHC MEDICARE GOLD MA|934.25||||||| 32551|EAP|0450|TUBE THORACOSTOMY|Veterans Affairs|VETERANS ADMINISTRATION|||||934.25||| 32555|EAP|0402|US GUIDED THORACENTESIS|Blue Cross PPO Specialty|BCBSTX OTHER|11.74||||11.74||| 326|DRG||STOMACH, ESOPHAGEAL & DUODENAL PROC W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|128,742.90|19988.19|19988.19|19988.19|||| 329|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W MCC|Medicare|MEDICARE ACUTE|151,969.49|35660.65|41558.79|35660.65|||| 329|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W MCC|Humana Medicare Advantage|HUMANA MA|340,127.81|41558.79|41558.79|35660.65|||| 329|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W MCC|United Medicare Advantage|AARP UHC WEST COMPLETE MA|53,532.30|35672.65|41558.79|35660.65|||| 330|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W CC|Medicare|MEDICARE ACUTE|50,025.20|20141.39|20141.39|7356.87|||| 330|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|41,932.05|7356.87|20141.39|7356.87|||| 330|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W CC|Humana Medicare Advantage|HUMANA MA|143,574.42|19840.48|20141.39|7356.87|||| 331|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W/O CC/MCC|Managed Medicare|HEALTHSPRING MA|25,295.30|14176.7|14220.22|6444.94|||| 331|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W/O CC/MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|31,959.55|14149.42|14220.22|6444.94|||| 331|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|26,698.40|6444.94|14220.22|6444.94|||| 331|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|23,841.80|14220.22|14220.22|6444.94|||| 331|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W/O CC/MCC|Medicare|MEDICARE ACUTE|28,058.80|14172.87|14220.22|6444.94|||| 331|DRG||MAJOR SMALL & LARGE BOWEL PROCEDURES W/O CC/MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|29,946.78|14170.86|14220.22|6444.94|||| 333|DRG||RECTAL RESECTION W CC|Medicare|MEDICARE ACUTE|47,965.18|16959.77|17983.55|16959.77|||| 333|DRG||RECTAL RESECTION W CC|Aenta Medicare Advantage|AETNA MEDICARE MA|31,299.05|17983.55|17983.55|16959.77|||| 334|DRG||RECTAL RESECTION W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|28,878.93|13219.97|13219.97|5353.6|||| 334|DRG||RECTAL RESECTION W/O CC/MCC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|26,814.40|5353.6|13219.97|5353.6|||| 335|DRG||PERITONEAL ADHESIOLYSIS W MCC|Managed Medicare|HEALTHSPRING MA|239,791.95|29913.25|29913.25|29913.25|||| 343|DRG||APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W/O CC/MCC|Aetna|AETNA PPO|26,876.70|14567.74|42959.4|10608.8|||| 343|DRG||APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|33,331.80|10608.8|42959.4|10608.8|||| 343|DRG||APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W/O CC/MCC|Managed Medicaid|MEDICAID SUPERIOR|30,403.85|16671.88|42959.4|10608.8|||| 343|DRG||APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W/O CC/MCC|NON CONTRACTED|COMMERCIAL OTHER 1|42,959.40|42959.4|42959.4|10608.8|||| 346|DRG||MINOR SMALL & LARGE BOWEL PROCEDURES W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|32,648.10|11502.49|11568.98|11502.49|||| 346|DRG||MINOR SMALL & LARGE BOWEL PROCEDURES W/O CC/MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|30,583.10|11568.98|11568.98|11502.49|||| 348|DRG||ANAL & STOMAL PROCEDURES W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|95,849.05|12307.94|12581.88|12279.78|||| 348|DRG||ANAL & STOMAL PROCEDURES W CC|Veterans Affairs|VETERANS ADMINISTRATION|37,651.24|12279.78|12581.88|12279.78|||| 348|DRG||ANAL & STOMAL PROCEDURES W CC|Humana Medicare Advantage|HUMANA MA|39,637.85|12581.88|12581.88|12279.78|||| 348|DRG||ANAL & STOMAL PROCEDURES W CC|Medicare|MEDICARE ACUTE|40,785.60|12527.14|12581.88|12279.78|||| 349|DRG||ANAL & STOMAL PROCEDURES W/O CC/MCC|Medicare|MEDICARE ACUTE|22,597.93|9608.2|9610.46|9608.2|||| 349|DRG||ANAL & STOMAL PROCEDURES W/O CC/MCC|United Medicare Advantage|AARP UHC WEST COMPLETE MA|26,360.93|9610.46|9610.46|9608.2|||| 354|DRG||HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|36,159.55|14396.48|14396.48|14396.48|||| 355|DRG||HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|37,532.30|12098.57|12098.57|12098.57|||| 36415|EAP|0300|COLLECTION FOR PKU|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|78.75||||18.75||| 36415|EAP|0300|VENIPUNCTURE FINGER HEEL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|95.25||||18.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Managed Medicare|HEALTHSPRING MA|78.75||||18.75||| 36415|EAP|0300|VENIPUNCTURE FINGER HEEL|Medicaid|MEDICAID|95.25||||18.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|78.75||||18.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Managed Medicaid|MEDICAID AMERIGROUP|78.75||||18.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Medicaid|MEDICAID|78.75||||18.75||| 36415|EAP|0300|COLLECTION FOR PKU|Managed Medicaid|MEDICAID AMERIGROUP|78.75||||18.75||| 36415|EAP|0300|VENIPUNCTURE FINGER HEEL|Medicaid|MOLINA HEALTHCARE OF TEXAS|95.25||||18.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Medicaid|MEDICAID HMO|||||18.75||| 36415|EAP|0300|VENIPUNCTURE FINGER HEEL|Managed Medicaid|MEDICAID SUPERIOR|95.25||||95.25||| 36415|EAP|0300|VENIPUNCTURE FINGER HEEL|Managed Medicaid|MEDICAID AMERIGROUP|95.25||||18.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Medicaid|MOLINA HEALTHCARE OF TEXAS|78.75||||18.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Managed Medicare|HOSPICE OF EAST TEXAS|78.75||||||| 36415|EAP|0300|PHLEBOTOMY FEE|Managed Medicaid|MEDICAID SUPERIOR|78.75||||18.75||| 36415|EAP|0300|PHLEBOTOMY FEE|UTMB|UTMB CORRECTIONAL MANAGED CARE|78.75||||78.75||| 36415|EAP|0300|VENIPUNCTURE FINGER HEEL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|95.25||||18.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Medicaid|COUNTY INDIGENT HEALTH OTHER|78.75||||18.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|78.75||||18.75||| 36415|EAP|0300|PHLEBOTOMY FEE|PHCS|HUMANA INSURANCE|||||18.75||| 36415|EAP|0300|COLLECTION FOR PKU|Medicaid|MEDICAID|78.75||||18.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Medicaid|SUPERIOR HEALTHPLAN CHIP|78.75||||18.75||| 36415|EAP|0300|PHLEBOTOMY FEE|NON CONTRACTED|COMMERCIAL OTHER 1|78.75||||18.75||| 36415|EAP|0300|PHLEBOTOMY FEE|NON CONTRACTED|COMMERCIAL OTHER 2|78.75||||78.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Medicare|MEDICARE PART B ONLY IP|78.75||||||| 36415|EAP|0300|VENIPUNCTURE FINGER HEEL|NON CONTRACTED|COMMERCIAL OTHER 1|95.25||||18.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Medicare|MEDICARE ACUTE|78.75||||18.75||| 36415|EAP|0300|VENIPUNCTURE FINGER HEEL|Tricare|TRICARE EAST REGION|95.25||||18.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|78.75||||48.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Managed Medicare|BCBS MEDICARE PPO MA|||||18.75||| 36415|EAP|0300|PHLEBOTOMY FEE|United Medicare Advantage|UHC MEDICARE GOLD MA|78.75||||18.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Tricare|TRICARE EAST REGION|78.75||||18.75||| 36415|EAP|0300|PHLEBOTOMY FEE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|78.75||||18.75||| 36415|EAP|0300|PHLEBOTOMY FEE|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|78.75||||18.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Workers Compensation|WORKERS COMPENSATION OTHER|78.75||||78.75||| 36415|EAP|0300|PHLEBOTOMY FEE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|78.75||||18.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Rusk State Hospital|RUSK STATE HOSP|78.75||||78.75||| 36415|EAP|0300|PHLEBOTOMY FEE|United Healthcare|TML GROUP BENEFITS|78.75||||18.75||| 36415|EAP|0300|PHLEBOTOMY FEE|United Healthcare|UNITED HEALTHCARE OTHER|78.75||||18.75||| 36415|EAP|0300|PHLEBOTOMY FEE|United Healthcare|UMR UNITED MEDICAL RESOURCES|78.75||||18.75||| 36415|EAP|0300|VENIPUNCTURE FINGER HEEL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|95.25||||18.75||| 36415|EAP|0300|VENIPUNCTURE FINGER HEEL|United Healthcare|UNITED HEALTHCARE OTHER|95.25||||18.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Workers Compensation|UT EMPLOYEE INJURY|78.75||||78.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Blue Cross HMO Specialty|BCBSTX HMO|78.75||||18.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Aetna|AETNA OTHER|78.75||||18.75||| 36415|EAP|0300|VENIPUNCTURE FINGER HEEL|United Healthcare|UNITED HEALTHCARE|95.25||||18.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Veterans Affairs|VETERANS ADMINISTRATION|78.75||||78.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||78.75||| 36415|EAP|0300|COLLECTION FOR PKU|Managed Medicaid|MEDICAID SUPERIOR|78.75||||18.75||| 36415|EAP|0300|PHLEBOTOMY FEE|United Healthcare|UNITED HEALTHCARE|78.75||||18.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|78.75||||18.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|78.75||||18.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Aetna|AETNA PPO|78.75||||18.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|78.75||||18.75||| 36415|EAP|0300|VENIPUNCTURE FINGER HEEL|Blue Cross HMO Specialty|BCBSTX HMO|95.25||||18.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|78.75||||18.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Aenta Medicare Advantage|AETNA MEDICARE MA|78.75||||18.75||| 36415|EAP|0300|VENIPUNCTURE FINGER HEEL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|95.25||||18.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|78.75||||18.75||| 36415|EAP|0300|COLLECTION FOR PKU|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|78.75||||18.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Aetna|BOON CHAPMAN|||||18.75||| 36415|EAP|0300|VENIPUNCTURE FINGER HEEL|Blue Cross PPO Specialty|BCBSTX PPO|95.25||||18.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Medicaid|MEDICAID TEXAS CHILDRENS|||||18.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|78.75||||18.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Cigna|CIGNA|78.75||||||| 36415|EAP|0300|VENIPUNCTURE FINGER HEEL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|95.25||||18.75||| 36415|EAP|0300|VENIPUNCTURE FINGER HEEL|Cigna|CIGNA|95.25||||18.75||| 36415|EAP|0300|COLLECTION FOR PKU|Blue Cross PPO Specialty|BCBSTX OTHER|78.75||||18.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|78.75||||18.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Blue Cross PPO Specialty|BCBSTX PPO|78.75||||18.75||| 36415|EAP|0300|VENIPUNCTURE FINGER HEEL|Blue Cross PPO Specialty|BCBSTX OTHER|78.75||||95.25||| 36415|EAP|0300|PHLEBOTOMY FEE|Cigna|CIGNA|||||18.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Cigna|CIGNA|78.75||||18.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Brinson Benefits|THE HEALTH PLAN SMITH CO|78.75||||||| 36415|EAP|0300|COLLECTION FOR PKU|Blue Cross PPO Specialty|BCBSTX PPO|78.75||||18.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Blue Cross PPO Specialty|BCBSTX OTHER|78.75||||48.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||18.75||| 36415|EAP|0300|PHLEBOTOMY FEE|Humana Medicare Advantage|HUMANA MA|78.75||||18.75||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|Medicare|MEDICARE ACUTE|11.22||||11.22||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||11.22||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|Blue Cross PPO Specialty|BCBSTX PPO|||||10.27||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|Blue Cross HMO Specialty|BCBSTX HMO|||||11.22||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||10.27||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|Humana Medicare Advantage|HUMANA MA|||||11.22||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|Blue Cross PPO Specialty|BCBSTX OTHER|||||10.27||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|Humana Medicare Advantage|HUMANA MA|||||10.27||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||11.22||| 36430|EAP|0391|TRANSFUSION 1-3 HRS|United Healthcare|UNITED HEALTHCARE OTHER|13.81||||11.22||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|Aenta Medicare Advantage|AETNA MEDICARE MA|11.22||||||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|United Healthcare|UNITED HEALTHCARE OTHER|10.27||||11.22||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|Blue Cross HMO Specialty|BCBSTX HMO|||||10.27||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|Medicare|MEDICARE ACUTE|10.27||||10.27||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||11.22||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|Blue Cross PPO Specialty|BCBSTX PPO|||||11.22||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|Medicaid|MEDICAID|||||10.27||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|Managed Medicaid|MEDICAID SUPERIOR|||||10.27||| 36430|EAP|0391|TRANSFUSION 1-3 HRS|Managed Medicaid|MEDICAID SUPERIOR|||||13.81||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|Medicaid|MEDICAID|||||11.22||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|NON CONTRACTED|COMMERCIAL OTHER 1|||||10.27||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||10.27||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|Aenta Medicare Advantage|AETNA MEDICARE MA|10.27||||||| 36430|EAP|0391|BLOOD TRANSFUSION SERVICE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||10.27||| 36556|EAP|0450|CVA NONTUNNELED 5YRS OR O|Medicare|MEDICARE ACUTE|2,068.75||||2,068.75||| 36556|EAP|0450|CVA NONTUNNELED 5YRS OR O|Managed Medicaid|MEDICAID SUPERIOR|||||2,068.75||| 36569|EAP|0361|INSERTION OF PICC LINE|Rusk State Hospital|RUSK STATE HOSP|29.35||||||| 36569|EAP|0361|INSERTION OF PICC LINE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|29.35||||||| 36569|EAP|0361|INSERTION OF PICC LINE|Veterans Affairs|VETERANS ADMINISTRATION|29.35||||||| 36569|EAP|0361|INSERTION OF PICC LINE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|29.35||||||| 36569|EAP|0361|INSERTION OF PICC LINE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|29.35||||||| 36569|EAP|0361|INSERTION OF PICC LINE|Humana Medicare Advantage|HUMANA MA|29.35||||||| 36569|EAP|0361|INSERTION OF PICC LINE|Blue Cross PPO Specialty|BCBSTX PPO|||||29.35||| 36569|EAP|0361|INSERTION OF PICC LINE|Medicare|MEDICARE ACUTE|29.35||||29.35||| 36569|EAP|0361|INSERTION OF PICC LINE|Managed Medicare|HEALTHSPRING MA|29.35||||||| 36569|EAP|0361|INSERTION OF PICC LINE|Brinson Benefits|THE HEALTH PLAN SMITH CO|29.35||||||| 36600|EAP|0412|ARTERIAL PUNCTURE|Managed Medicare|HEALTHSPRING MA|203.25||||203.25||| 36600|EAP|0412|ARTERIAL PUNCTURE|Managed Medicaid|MEDICAID SUPERIOR|203.25||||203.25||| 36600|EAP|0412|ARTERIAL PUNCTURE|Managed Medicaid|MEDICAID AMERIGROUP|203.25||||||| 36600|EAP|0412|ARTERIAL PUNCTURE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|203.25||||203.25||| 36600|EAP|0412|ARTERIAL PUNCTURE|UTMB|UTMB CORRECTIONAL MANAGED CARE|203.25||||203.25||| 36600|EAP|0412|ARTERIAL PUNCTURE|Medicaid|COUNTY INDIGENT HEALTH OTHER|203.25||||||| 36600|EAP|0412|ARTERIAL PUNCTURE|Medicare|MEDICARE ACUTE|203.25||||203.25||| 36600|EAP|0412|ARTERIAL PUNCTURE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||203.25||| 36600|EAP|0412|ARTERIAL PUNCTURE|Medicaid|MEDICAID|203.25||||203.25||| 36600|EAP|0412|ARTERIAL PUNCTURE|Rusk State Hospital|RUSK STATE HOSP|203.25||||203.25||| 36600|EAP|0412|ARTERIAL PUNCTURE|Managed Medicare|HOSPICE OF EAST TEXAS|203.25||||||| 36600|EAP|0412|ARTERIAL PUNCTURE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|203.25||||203.25||| 36600|EAP|0412|ARTERIAL PUNCTURE|Blue Cross PPO Specialty|BCBSTX OTHER|203.25||||||| 36600|EAP|0940|ARTERIAL PUNCTURE BY NURS|Medicaid|MEDICAID|105.75||||||| 36600|EAP|0412|ARTERIAL PUNCTURE|NON CONTRACTED|COMMERCIAL OTHER 1|203.25||||203.25||| 36600|EAP|0412|ARTERIAL PUNCTURE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||203.25||| 36600|EAP|0412|ARTERIAL PUNCTURE|Blue Cross PPO Specialty|BCBSTX PPO|203.25||||203.25||| 36600|EAP|0412|ARTERIAL PUNCTURE|Humana Medicare Advantage|HUMANA MA|203.25||||203.25||| 36600|EAP|0412|ARTERIAL PUNCTURE|Cigna|CIGNA|203.25||||203.25||| 36600|EAP|0412|ARTERIAL PUNCTURE|Tricare|TRICARE EAST REGION|||||203.25||| 36600|EAP|0412|ARTERIAL PUNCTURE|Blue Cross HMO Specialty|BCBSTX HMO|203.25||||203.25||| 36600|EAP|0412|ARTERIAL PUNCTURE|United Healthcare|TML GROUP BENEFITS|203.25||||||| 36600|EAP|0412|ARTERIAL PUNCTURE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|203.25||||203.25||| 36600|EAP|0412|ARTERIAL PUNCTURE|United Medicare Advantage|UHC MEDICARE GOLD MA|203.25||||203.25||| 36600|EAP|0412|ARTERIAL PUNCTURE|United Healthcare|UNITED HEALTHCARE|203.25||||||| 36600|EAP|0412|ARTERIAL PUNCTURE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|203.25||||203.25||| 36600|EAP|0412|ARTERIAL PUNCTURE|Workers Compensation|UT EMPLOYEE INJURY|203.25||||||| 36600|EAP|0412|ARTERIAL PUNCTURE|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|203.25||||||| 36600|EAP|0412|ARTERIAL PUNCTURE|Aenta Medicare Advantage|AETNA MEDICARE MA|203.25||||203.25||| 36600|EAP|0412|ARTERIAL PUNCTURE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|203.25||||203.25||| 36600|EAP|0412|ARTERIAL PUNCTURE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|203.25||||||| 36600|EAP|0412|ARTERIAL PUNCTURE|Veterans Affairs|VETERANS ADMINISTRATION|||||203.25||| 36600|EAP|0412|ARTERIAL PUNCTURE|United Healthcare|UNITED HEALTHCARE OTHER|||||203.25||| 369|DRG||MAJOR ESOPHAGEAL DISORDERS W CC|Aetna|AETNA PPO|37,387.25|115.04|115.04|115.04|||| 371|DRG||MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W MCC|Cigna|CIGNA|41,508.45|11694.99|11694.99|11694.99|||| 37195|EAP|0480|THROMBOLYSIS CEREBRAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||5.20||| 37195|EAP|0480|THROMBOLYSIS CEREBRAL|Humana Medicare Advantage|HUMANA MA|||||5.20||| 37195|EAP|0480|THROMBOLYSIS CEREBRAL|Blue Cross PPO Specialty|BCBSTX PPO|||||5.20||| 372|DRG||MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W CC|Medicare|MEDICARE ACUTE|57,844.90|9806.365|9806.365|9723.41|||| 372|DRG||MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTIONS W CC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|693.91|9723.41|9806.365|9723.41|||| 375|DRG||DIGESTIVE MALIGNANCY W CC|Veterans Affairs|VETERANS ADMINISTRATION|83,950.64|11153.59|11153.59|11153.59|||| 377|DRG||G.I. HEMORRHAGE W MCC|Medicare|MEDICARE ACUTE|42,359.30|14684.46|14684.46|14684.46|||| 378|DRG||G.I. HEMORRHAGE W CC|Medicare|MEDICARE ACUTE|38,367.10|7413.29|7413.29|7413.29|||| 38505|EAP|0400|US GUIDED BX LYMPH NODES|Medicare|MEDICARE ACUTE|||||12.31||| 388|DRG||G.I. OBSTRUCTION W MCC|Medicare|MEDICARE ACUTE|81,174.30|13197.09|13197.09|13080.59|||| 388|DRG||G.I. OBSTRUCTION W MCC|Managed Medicare|HOSPICE OF EAST TEXAS|9,747.75|13080.59|13197.09|13080.59|||| 389|DRG||G.I. OBSTRUCTION W CC|Humana Medicare Advantage|HUMANA MA|59,131.25|8507.05|8648.04|8507.05|||| 389|DRG||G.I. OBSTRUCTION W CC|Veterans Affairs|VETERANS ADMINISTRATION|67,675.93|8648.04|8648.04|8507.05|||| 390|DRG||G.I. OBSTRUCTION W/O CC/MCC|Rusk State Hospital|RUSK STATE HOSP|40,099.25|19648.63|19648.63|5807.86|||| 390|DRG||G.I. OBSTRUCTION W/O CC/MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|32,749.95|5807.86|19648.63|5807.86|||| 391|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W MCC|Medicare|MEDICARE ACUTE|58,730.80|12121.58|12121.58|12121.58|||| 392|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC|Humana Medicare Advantage|HUMANA MA|573.93|8014.22|8115.03|339.26|||| 392|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|56,827.56|8115.03|8115.03|339.26|||| 392|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC|Medicaid|MOLINA HEALTHCARE OF TEXAS|21,151.50|5085.69|8115.03|339.26|||| 392|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC|Medicare|MEDICARE PART B ONLY IP|16,052.30|339.26|8115.03|339.26|||| 392|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC|United Healthcare|UMR UNITED MEDICAL RESOURCES|32,428.05|7608.15|8115.03|339.26|||| 392|DRG||ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC|Medicare|MEDICARE ACUTE|36,133.63|7978.72|8115.03|339.26|||| 394|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W CC|Medicare|MEDICARE ACUTE|30,512.58|9237.485|13357.39|2485.92|||| 394|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W CC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|60,535.25|2485.92|13357.39|2485.92|||| 394|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|41,411.63|13357.39|13357.39|2485.92|||| 395|DRG||OTHER DIGESTIVE SYSTEM DIAGNOSES W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|40,873.55|2572.73|2572.73|2572.73|||| 4|DRG||TRACH W MV >96 HRS OR PDX EXC FACE, MOUTH & NECK W/O MAJ O.R.|Humana Medicare Advantage|HUMANA MA|739,602.82|132992.36|132992.36|132992.36|||| 417|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W MCC|United Medicare Advantage|AARP UHC WEST COMPLETE MA|39,950.55|18996.95|18996.95|18996.95|||| 418|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W CC|Humana Medicare Advantage|HUMANA MA|74,447.80|14360.79|14360.79|5861.31|||| 418|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W CC|Blue Cross HMO Specialty|BCBSTX HMO|48,600.90|5861.31|14360.79|5861.31|||| 418|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W CC|Medicare|MEDICARE ACUTE|78,510.60|14038.2|14360.79|5861.31|||| 419|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W/O CC/MCC|United Healthcare|UNITED HEALTHCARE|36,931.91|13056.24|13056.24|5403.3|||| 419|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W/O CC/MCC|United Healthcare|UNITED HEALTHCARE|55,971.50|13056.24|13056.24|5403.3|||| 419|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W/O CC/MCC|United Healthcare|UMR UNITED MEDICAL RESOURCES|46,757.40|5403.3|13056.24|5403.3|||| 419|DRG||LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|492.05|11657.88|13056.24|5403.3|||| 42700|EAP|0450|I&D ABSCESS PERITONSILLAR|Managed Medicaid|MEDICAID AMERIGROUP|||||605.25||| 43235|EAP|0750|EGD DX|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||3,046.25||| 43235|EAP|0750|EGD DX|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3,046.25||| 43235|EAP|0750|EGD DX|Blue Cross PPO Specialty|BCBSTX PPO|||||3,046.25||| 43235|EAP|0750|EGD DX|Humana Medicare Advantage|HUMANA MA|||||3,046.25||| 43235|EAP|0750|EGD DX|Managed Medicaid|MEDICAID AMERIGROUP|||||3,046.25||| 43235|EAP|0750|EGD DX|Medicare|MEDICARE ACUTE|3,046.25||||3,046.25||| 43236|EAP|0750|UPPR GI SCOPE W/SUBMUC IN|Managed Medicaid|MEDICAID AMERIGROUP|||||20.44||| 43239|EAP|0750|GASTROSCOPY W/ BIOPSY|Humana Medicare Advantage|HUMANA MA|||||22.77||| 43239|EAP|0750|GASTROSCOPY W/ BIOPSY|Blue Cross PPO Specialty|BCBSTX PPO|||||22.77||| 43239|EAP|0750|GASTROSCOPY W/ BIOPSY|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||22.77||| 43239|EAP|0750|GASTROSCOPY W/ BIOPSY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||22.77||| 43239|EAP|0750|GASTROSCOPY W/ BIOPSY|Blue Cross HMO Specialty|BCBSTX HMO|||||22.77||| 43239|EAP|0750|GASTROSCOPY W/ BIOPSY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||22.77||| 43239|EAP|0750|GASTROSCOPY W/ BIOPSY|United Medicare Advantage|UHC MEDICARE GOLD MA|||||22.77||| 43239|EAP|0750|GASTROSCOPY W/ BIOPSY|Medicare|MEDICARE ACUTE|||||22.77||| 43239|EAP|0750|GASTROSCOPY W/ BIOPSY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||22.77||| 43239|EAP|0750|GASTROSCOPY W/ BIOPSY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||22.77||| 43239|EAP|0750|GASTROSCOPY W/ BIOPSY|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||22.77||| 43246|EAP|0750|EGD W/PLACE TUBE|Medicare|MEDICARE ACUTE|2,784.25||||||| 43246|EAP|0750|EGD W/PLACE TUBE|Humana Medicare Advantage|HUMANA MA|2,784.25||||||| 43248|EAP|0750|EGD W/INSERT GUIDEWIRE|United Healthcare|UNITED HEALTHCARE OTHER|||||3,712.25||| 43248|EAP|0750|EGD W/INSERT GUIDEWIRE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||3,712.25||| 43248|EAP|0750|EGD W/INSERT GUIDEWIRE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||3,712.25||| 43248|EAP|0750|EGD W/INSERT GUIDEWIRE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||3,712.25||| 43248|EAP|0750|EGD W/INSERT GUIDEWIRE|Medicare|MEDICARE ACUTE|||||3,712.25||| 43248|EAP|0750|EGD W/INSERT GUIDEWIRE|Blue Cross PPO Specialty|BCBSTX PPO|||||3,712.25||| 43248|EAP|0750|EGD W/INSERT GUIDEWIRE|Humana Medicare Advantage|HUMANA MA|||||3,712.25||| 433|DRG||CIRRHOSIS & ALCOHOLIC HEPATITIS W CC|Medicare|MEDICARE ACUTE|41,531.05|9784.51|21050.93|9784.51|||| 433|DRG||CIRRHOSIS & ALCOHOLIC HEPATITIS W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|27,051.50|13554.7|21050.93|9784.51|||| 433|DRG||CIRRHOSIS & ALCOHOLIC HEPATITIS W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|55,480.75|21050.93|21050.93|9784.51|||| 43752|EAP|0450|PLCMNT TUBE NASO ORO GAST|Medicare|MEDICARE ACUTE|516.50||||||| 43752|EAP|0450|PLCMNT TUBE NASO ORO GAST|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|516.50||||||| 43752|EAP|0450|PLCMNT TUBE NASO ORO GAST|Humana Medicare Advantage|HUMANA MA|516.50||||||| 43762|EAP|0450|CHANGE GASTROSTOMY TUBE|Blue Cross PPO Specialty|BCBSTX PPO|||||738.75||| 43762|EAP|0450|CHANGE GASTROSTOMY TUBE|Medicare|MEDICARE ACUTE|738.75||||738.75||| 43762|EAP|0450|CHANGE GASTROSTOMY TUBE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||738.75||| 43762|EAP|0450|CHANGE GASTROSTOMY TUBE|Humana Medicare Advantage|HUMANA MA|||||738.75||| 438|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W MCC|Medicare|MEDICARE ACUTE|94,580.59|14087.47|14087.47|14087.47|||| 439|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|35,815.55|8699.16|13835.43|8697.2|||| 439|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W CC|Medicare|MEDICARE ACUTE|33,443.68|8697.2|13835.43|8697.2|||| 439|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|65,082.58|13835.43|13835.43|8697.2|||| 440|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W/O CC/MCC|United Healthcare|UMR UNITED MEDICAL RESOURCES|29,381.85|6150.46|7005.45|31.5|||| 440|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|202.21|2206.55|7005.45|31.5|||| 440|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W/O CC/MCC|Cigna|CIGNA|14,223.05|31.5|7005.45|31.5|||| 440|DRG||DISORDERS OF PANCREAS EXCEPT MALIGNANCY W/O CC/MCC|United Medicare Advantage|AARP UHC WEST COMPLETE MA|24,411.30|7005.45|7005.45|31.5|||| 441|DRG||DISORDERS OF LIVER EXCEPT MALIG, CIRR, ALC HEPA W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|39,617.50|13659.55|13659.55|13659.55|||| 442|DRG||DISORDERS OF LIVER EXCEPT MALIG, CIRR, ALC HEPA W CC|Medicare|MEDICARE ACUTE|47,794.12|9126.13|9286.7|9126.13|||| 442|DRG||DISORDERS OF LIVER EXCEPT MALIG, CIRR, ALC HEPA W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|44,202.25|9286.7|9286.7|9126.13|||| 443|DRG||DISORDERS OF LIVER EXCEPT MALIG, CIRR, ALC HEPA W/O CC/MCC|Medicare|MEDICARE ACUTE|22,502.35|7436.08|13590.81|7436.08|||| 443|DRG||DISORDERS OF LIVER EXCEPT MALIG, CIRR, ALC HEPA W/O CC/MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|290.92|13590.81|13590.81|7436.08|||| 45305|EAP|0361|PROCTOSIGMOIDOSCOPY/RIGID|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4,091.50||||||| 45331|EAP|0750|SIGMOIDOSCOPY,FLEXIBLE|Humana Medicare Advantage|HUMANA MA|||||18.08||| 45378|EAP|0750|COLONOSCOPY|Cigna|CIGNA|||||3,712.25||| 45378|EAP|0750|COLONOSCOPY|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||3,712.25||| 45378|EAP|0750|COLONOSCOPY|NON CONTRACTED|COMMERCIAL OTHER 1|||||3,712.25||| 45378|EAP|0750|COLONOSCOPY|Blue Cross HMO Specialty|BCBSTX HMO|||||3,712.25||| 45378|EAP|0750|COLONOSCOPY|Medicare|MEDICARE ACUTE|||||3,712.25||| 45380|EAP|0750|COLONOSCOPY WITH BIOPSY|Cigna|CIGNA|||||3,843.25||| 45380|EAP|0750|COLONOSCOPY WITH BIOPSY|Humana Medicare Advantage|HUMANA MA|||||3,843.25||| 45380|EAP|0750|COLONOSCOPY WITH BIOPSY|United Healthcare|UNITED HEALTHCARE OTHER|||||3,843.25||| 45380|EAP|0750|COLONOSCOPY WITH BIOPSY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||3,843.25||| 45380|EAP|0750|COLONOSCOPY WITH BIOPSY|Managed Medicare|HEALTHSPRING MA|||||3,843.25||| 45380|EAP|0750|COLONOSCOPY WITH BIOPSY|Blue Cross PPO Specialty|BCBSTX OTHER|||||3,843.25||| 45380|EAP|0750|COLONOSCOPY WITH BIOPSY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3,843.25||| 45380|EAP|0750|COLONOSCOPY WITH BIOPSY|Aetna|AETNA PPO|||||3,843.25||| 45380|EAP|0750|COLONOSCOPY WITH BIOPSY|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||3,843.25||| 45380|EAP|0750|COLONOSCOPY WITH BIOPSY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||3,843.25||| 45380|EAP|0750|COLONOSCOPY WITH BIOPSY|NON CONTRACTED|COMMERCIAL OTHER 1|||||3,843.25||| 45380|EAP|0750|COLONOSCOPY WITH BIOPSY|Medicare|MEDICARE ACUTE|||||3,843.25||| 45380|EAP|0750|COLONOSCOPY WITH BIOPSY|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||3,843.25||| 45380|EAP|0750|COLONOSCOPY WITH BIOPSY|Blue Cross HMO Specialty|BCBSTX HMO|||||3,843.25||| 45380|EAP|0750|COLONOSCOPY WITH BIOPSY|Blue Cross PPO Specialty|BCBSTX PPO|||||3,843.25||| 462|DRG||BILATERAL OR MULTIPLE MAJOR JOINT PROCS OF LOWER EXTREMITY W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|55,937.55|13233.16|23836.37|13233.16|||| 462|DRG||BILATERAL OR MULTIPLE MAJOR JOINT PROCS OF LOWER EXTREMITY W/O MCC|Medicare|MEDICARE ACUTE|86,373.23|23836.37|23836.37|13233.16|||| 464|DRG||WND DEBRID & SKN GRFT EXC HAND, FOR MUSCULO-CONN TISS DIS W CC|Humana Medicare Advantage|HUMANA MA|84,300.20|23158.02|23158.02|23158.02|||| 465|DRG||WND DEBRID & SKN GRFT EXC HAND, FOR MUSCULO-CONN TISS DIS W/O CC/MCC|Brinson Benefits|THE HEALTH PLAN SMITH CO|104,290.10|28761.5|28761.5|28761.5|||| 467|DRG||REVISION OF HIP OR KNEE REPLACEMENT W CC|Medicare|MEDICARE ACUTE|143,545.25|26854.88|26854.88|15635.93|||| 467|DRG||REVISION OF HIP OR KNEE REPLACEMENT W CC|Blue Cross PPO Specialty|BCBSTX PPO|119,791.04|15635.93|26854.88|15635.93|||| 468|DRG||REVISION OF HIP OR KNEE REPLACEMENT W/O CC/MCC|Medicare|MEDICARE ACUTE|39,536.40|21643.62|39155.99|21643.62|||| 468|DRG||REVISION OF HIP OR KNEE REPLACEMENT W/O CC/MCC|Cigna|CIGNA|78,088.30|30670.95|39155.99|21643.62|||| 468|DRG||REVISION OF HIP OR KNEE REPLACEMENT W/O CC/MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|43,824.70|39155.99|39155.99|21643.62|||| 469|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W MCC OR TOTAL ANKLE REPLACE|Medicare|MEDICARE ACUTE|87,757.80|24318.84|24326.11|24216.215|||| 469|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W MCC OR TOTAL ANKLE REPLACE|Humana Medicare Advantage|HUMANA MA|92,794.33|24216.215|24326.11|24216.215|||| 469|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W MCC OR TOTAL ANKLE REPLACE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|74,697.90|24326.11|24326.11|24216.215|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Blue Cross HMO Specialty|BCBSTX HMO|43,388.38|7008.08|65671.505|7008.08|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|45,680.73|7567.21|65671.505|7008.08|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|91,496.80|16718.55|65671.505|7008.08|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|77,489.15|16014.4|65671.505|7008.08|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|38,518.55|8243.74|65671.505|7008.08|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|44,873.40|7008.08|65671.505|7008.08|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|42,782.45|36516.02|65671.505|7008.08|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Humana Medicare Advantage|HUMANA MA|44,741.35|16104.08|65671.505|7008.08|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|44,802.48|16015.4|65671.505|7008.08|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Workers Compensation|WORKERS COMPENSATION OTHER|45,498.60|23367.95|65671.505|7008.08|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Tricare|TRICARE EAST REGION|42,276.43|10845.45|65671.505|7008.08|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Medicare|MEDICARE ACUTE|60,702.75|16037.22|65671.505|7008.08|||| 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|62,065.03|16042.12|65671.505|7008.08|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|NON CONTRACTED|COMMERCIAL OTHER 1|92,898.73|65671.505|65671.505|7008.08|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|78,242.30|16014.4|65671.505|7008.08|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|United Medicare Advantage|AARP UHC WEST COMPLETE MA|45,424.50|16341.22|65671.505|7008.08|||| 470|DRG||MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC|Managed Medicaid|MEDICAID SUPERIOR|44,960.30|39674.49|65671.505|7008.08|||| 480|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W MCC|Medicare|MEDICARE ACUTE|180,084.45|23491.67|30055.12|23491.67|||| 480|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|89,149.10|30055.12|30055.12|23491.67|||| 481|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W CC|Medicare|MEDICARE ACUTE|61,392.35|16835.35|24531.68|16835.35|||| 481|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W CC|Workers Compensation|WORKERS COMPENSATION OTHER|63,066.05|24531.68|24531.68|16835.35|||| 481|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|137,657.29|17155.02|24531.68|16835.35|||| 481|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W CC|Humana Medicare Advantage|HUMANA MA|75,384.09|16910.6|24531.68|16835.35|||| 482|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|54,613.55|16917.4|16917.4|13625.09|||| 482|DRG||HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC|Medicare|MEDICARE ACUTE|42,924.85|13625.09|16917.4|13625.09|||| 483|DRG||MAJOR JOINT/LIMB REATTACHMENT PROCEDURE OF UPPER EXTREMITIES|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|35,495.50|9064.45|19316.52|9064.45|||| 483|DRG||MAJOR JOINT/LIMB REATTACHMENT PROCEDURE OF UPPER EXTREMITIES|Humana Medicare Advantage|HUMANA MA|30,494.75|19316.52|19316.52|9064.45|||| 483|DRG||MAJOR JOINT/LIMB REATTACHMENT PROCEDURE OF UPPER EXTREMITIES|Medicare|MEDICARE ACUTE|46,480.08|19045.005|19316.52|9064.45|||| 483|DRG||MAJOR JOINT/LIMB REATTACHMENT PROCEDURE OF UPPER EXTREMITIES|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|32,947.80|18872.71|19316.52|9064.45|||| 489|DRG||KNEE PROCEDURES W/O PDX OF INFECTION W/O CC/MCC|Medicare|MEDICARE ACUTE|31,641.10|11301.16|11505.97|11301.16|||| 489|DRG||KNEE PROCEDURES W/O PDX OF INFECTION W/O CC/MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|32,419.05|11505.97|11505.97|11301.16|||| 493|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W CC|Humana Medicare Advantage|HUMANA MA|56,332.15|18699.09|18699.09|17329.755|||| 493|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W CC|Medicare|MEDICARE ACUTE|46,684.23|17329.755|18699.09|17329.755|||| 494|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|34,677.30|6670.08|14965.7|6670.08|||| 494|DRG||LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR W/O CC/MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|50,649.10|14965.7|14965.7|6670.08|||| 49406|EAP|0350|DRAIN BY CATHETER RETRO/P|Medicare|MEDICARE ACUTE|||||1,139.25||| 498|DRG||LOCAL EXCISION & REMOVAL INT FIX DEVICES OF HIP & FEMUR W CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|41,033.10|8663.23|8663.23|8663.23|||| 501|DRG||SOFT TISSUE PROCEDURES W CC|Medicare|MEDICARE ACUTE|48,670.98|14029.745|14029.745|14029.745|||| 511|DRG||SHOULDER, ELBOW OR FOREARM PROC, EXC MAJOR JOINT PROC W CC|Medicare|MEDICARE ACUTE|67,297.25|15762.95|15762.95|15762.95|||| 512|DRG||SHOULDER, ELBOW OR FOREARM PROC, EXC MAJOR JOINT PROC W/O CC/MCC|Medicare|MEDICARE ACUTE|29,590.85|13002.57|27182.81|13002.57|||| 512|DRG||SHOULDER, ELBOW OR FOREARM PROC, EXC MAJOR JOINT PROC W/O CC/MCC|Managed Medicaid|MEDICAID AMERIGROUP|32,618.05|27182.81|27182.81|13002.57|||| 514|DRG||HAND OR WRIST PROC, EXCEPT MAJOR THUMB OR JOINT PROC W/O CC/MCC|Medicaid|MEDICAID|26,006.85|12402.67|12402.67|4142.17|||| 514|DRG||HAND OR WRIST PROC, EXCEPT MAJOR THUMB OR JOINT PROC W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|20,562.60|4142.17|12402.67|4142.17|||| 51600|EAP|0320|INJ CYSTOGRAPHY OR VOIDIN|Managed Medicaid|MEDICAID AMERIGROUP|264.25||||||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|United Medicare Advantage|UHC MEDICARE GOLD MA|2.26||||2.26||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|United Healthcare|UNITED HEALTHCARE OTHER|||||2.26||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|United Medicare Advantage|AARP UHC WEST COMPLETE MA|2.26||||2.26||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.26||||2.26||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2.26||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Blue Cross PPO Specialty|BCBSTX OTHER|||||2.26||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Aenta Medicare Advantage|AETNA MEDICARE MA|2.26||||2.26||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||2.26||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Blue Cross PPO Specialty|BCBSTX PPO|||||2.26||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.26||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Blue Cross HMO Specialty|BCBSTX HMO|2.26||||2.26||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Medicare|MEDICARE ACUTE|2.26||||2.26||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||2.26||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Medicaid|MEDICAID|2.26||||2.26||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||2.26||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|NON CONTRACTED|COMMERCIAL OTHER 1|||||2.26||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.26||||||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Rusk State Hospital|RUSK STATE HOSP|2.26||||2.26||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Humana Medicare Advantage|HUMANA MA|2.26||||2.26||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.26||||2.26||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Cigna|CIGNA|||||2.26||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Managed Medicaid|MEDICAID AMERIGROUP|||||2.26||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Managed Medicare|HEALTHSPRING MA|2.26||||||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Managed Medicaid|MEDICAID SUPERIOR|2.26||||2.26||| 51701|EAP|0450|INSERT BLADDER CATH STRAI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.26||||2.26||| 51702|EAP|0450|INSERT FOLEY SIMPL|Managed Medicare|HEALTHSPRING MA|294.50||||||| 51702|EAP|0450|INSERT FOLEY SIMPL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||294.50||| 51702|EAP|0450|INSERT FOLEY SIMPL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||294.50||| 51702|EAP|0450|INSERT FOLEY SIMPL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|294.50||||294.50||| 51702|EAP|0450|INSERT FOLEY SIMPL|Medicare|MEDICARE ACUTE|294.50||||294.50||| 51702|EAP|0450|INSERT FOLEY SIMPL|Rusk State Hospital|RUSK STATE HOSP|||||294.50||| 51702|EAP|0450|INSERT FOLEY SIMPL|Managed Medicaid|MEDICAID SUPERIOR|294.50||||294.50||| 51702|EAP|0450|INSERT FOLEY SIMPL|Medicaid|MEDICAID|294.50||||294.50||| 51702|EAP|0450|INSERT FOLEY SIMPL|Managed Medicare|HOSPICE OF EAST TEXAS|294.50||||||| 51702|EAP|0450|INSERT FOLEY SIMPL|Medicaid|COUNTY INDIGENT HEALTH OTHER|294.50||||||| 51702|EAP|0450|INSERT FOLEY SIMPL|UTMB|UTMB CORRECTIONAL MANAGED CARE|294.50||||294.50||| 51702|EAP|0450|INSERT FOLEY SIMPL|Aenta Medicare Advantage|AETNA MEDICARE MA|294.50||||294.50||| 51702|EAP|0450|INSERT FOLEY SIMPL|Blue Cross PPO Specialty|BCBSTX PPO|||||294.50||| 51702|EAP|0450|INSERT FOLEY SIMPL|Cigna|CIGNA|||||294.50||| 51702|EAP|0450|INSERT FOLEY SIMPL|Humana Medicare Advantage|HUMANA MA|294.50||||294.50||| 51702|EAP|0450|INSERT FOLEY SIMPL|United Medicare Advantage|UHC MEDICARE GOLD MA|294.50||||294.50||| 51702|EAP|0450|INSERT FOLEY SIMPL|Blue Cross HMO Specialty|BCBSTX HMO|294.50||||294.50||| 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|Workers Compensation|WORKERS COMPENSATION OTHER|||||294.50||| 51702|EAP|0361|CATH URETHRA, SIMPLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||237.75||| 51702|EAP|0450|INSERT FOLEY SIMPL|United Healthcare|UNITED HEALTHCARE OTHER|||||294.50||| 51784|EAP|0750|ANAL/URINARY MUSCLE STUDY|Blue Cross PPO Specialty|BCBSTX PPO|||||5.44||| 51784|EAP|0750|ANAL/URINARY MUSCLE STUDY|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||5.44||| 51784|EAP|0750|ANAL/URINARY MUSCLE STUDY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||5.44||| 51784|EAP|0750|ANAL/URINARY MUSCLE STUDY|Tricare|TRICARE EAST REGION|||||5.44||| 51784|EAP|0750|ANAL/URINARY MUSCLE STUDY|Humana Medicare Advantage|HUMANA MA|||||5.44||| 51784|EAP|0750|ANAL/URINARY MUSCLE STUDY|Medicare|MEDICARE ACUTE|||||5.44||| 54150|EAP|0360|CIRCUMCISION W/MAT-OP|Managed Medicaid|MEDICAID AMERIGROUP|18.00||||18.00||| 54150|EAP|0360|CIRCUMCISION W/MAT-OP|Medicaid|MEDICAID|18.00||||18.00||| 54150|EAP|0360|CIRCUMCISION W/MAT-OP|Managed Medicaid|MEDICAID SUPERIOR|||||18.00||| 54150|EAP|0360|CIRCUMCISION W/MAT-OP|United Healthcare|UNITED HEALTHCARE|18.00||||||| 54150|EAP|0360|CIRCUMCISION W/MAT-OP|United Healthcare|UNITED HEALTHCARE OTHER|||||18.00||| 54220|EAP|0450|IRR CORPORA CAVERNOSA PRI|Rusk State Hospital|RUSK STATE HOSP|||||656.50||| 54415|EAP|0450|REMOVAL PENILE PROSTHESIS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||60.44||| 549|DRG||SEPTIC ARTHRITIS W CC|Aenta Medicare Advantage|AETNA MEDICARE MA|82,246.60|11056.81|11056.81|11056.81|||| 552|DRG||MEDICAL BACK PROBLEMS W/O MCC|Medicare|MEDICARE ACUTE|55,788.05|8982.56|8984.63|8982.56|||| 552|DRG||MEDICAL BACK PROBLEMS W/O MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|42,007.60|8984.63|8984.63|8982.56|||| 554|DRG||BONE DISEASES & ARTHROPATHIES W/O MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|59,091.25|8150.8|8150.8|8150.8|||| 560|DRG||AFTERCARE, MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|10,726.50|10726.5|10726.5|9862.19|||| 560|DRG||AFTERCARE, MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE W CC|Medicare|MEDICARE ACUTE|33,226.80|9862.19|10726.5|9862.19|||| 563|DRG||FX, SPRN, STRN & DISL EXCEPT FEMUR, HIP, PELVIS & THIGH W/O MCC|NON CONTRACTED|COMMERCIAL OTHER 1|22,898.85|18.9|18.9|18.9|||| 564|DRG||OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W MCC|Medicare|MEDICARE ACUTE|69,199.45|11673.1|11673.1|11673.1|||| 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 SUPERIOR|||||742.50||| 57|DRG||DEGENERATIVE NERVOUS SYSTEM DISORDERS W/O MCC|Humana Medicare Advantage|HUMANA MA|76,446.25|11032.48|11032.48|11032.48|||| 571|DRG||SKIN DEBRIDEMENT W CC|Blue Cross HMO Specialty|BCBSTX HMO|36,810.80|5997.61|5997.61|5997.61|||| 572|DRG||SKIN DEBRIDEMENT W/O CC/MCC|Medicare|MEDICARE ACUTE|27,902.55|10567.55|10567.55|10567.55|||| 580|DRG||OTHER SKIN, SUBCUT TISS & BREAST PROC W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|111,070.35|6046.01|6046.01|6046.01|||| 581|DRG||OTHER SKIN, SUBCUT TISS & BREAST PROC W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|38,603.55|4702.03|4702.03|4702.03|||| 58340|EAP|0320|CATH/INTRO CONTRAST MATER|Managed Medicaid|MEDICAID SUPERIOR|||||264.25||| 59025|EAP|0729|NON STRESS TEST/FETAL MON|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2,033.75||| 59025|EAP|0729|NON STRESS TEST/FETAL MON|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2,033.75||||2,033.75||| 59025|EAP|0729|NON STRESS TEST/FETAL MON|Cigna|CIGNA|||||2,033.75||| 59025|EAP|0729|NON STRESS TEST/FETAL MON|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2,033.75||| 59025|EAP|0729|NON STRESS TEST/FETAL MON|Blue Cross PPO Specialty|BCBSTX PPO|2,033.75||||2,033.75||| 59025|EAP|0729|NON STRESS TEST/FETAL MON|Medicaid|MEDICAID|2,033.75||||2,033.75||| 59025|EAP|0729|NON STRESS TEST/FETAL MON|Blue Cross HMO Specialty|BCBSTX HMO|2,033.75||||2,033.75||| 59025|EAP|0729|NON STRESS TEST/FETAL MON|United Healthcare|UNITED HEALTHCARE OTHER|2,033.75||||2,033.75||| 59025|EAP|0729|NON STRESS TEST/FETAL MON|NON CONTRACTED|COMMERCIAL OTHER 2|2,033.75||||2,033.75||| 59025|EAP|0729|NON STRESS TEST/FETAL MON|United Healthcare|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|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||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|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2,033.75||||2,033.75||| 59025|EAP|0729|NON STRESS TEST/FETAL MON|Medicaid|MEDICAID TEXAS CHILDRENS|||||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|Managed Medicaid|MEDICAID AMERIGROUP|2,033.75||||2,033.75||| 59025|EAP|0729|NON STRESS TEST/FETAL MON|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2,033.75||||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|Tricare|TRICARE EAST REGION|||||2,033.75||| 59400|EAP|0720|LABOR & DELIVERY|Managed Medicaid|MEDICAID SUPERIOR|14,912.25||||||| 59400|EAP|0720|LABOR & DELIVERY LEVEL I|Managed Medicaid|MEDICAID SUPERIOR|110.96||||||| 59400|EAP|0720|LABOR & DELIVERY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|14,912.25||||||| 59400|EAP|0720|LABOR & DELIVERY LEVEL I|Managed Medicaid|MEDICAID UNITED HEALTHCARE|110.96||||||| 59400|EAP|0720|LABOR & DELIVERY|Managed Medicaid|MEDICAID AMERIGROUP|14,912.25||||||| 59400|EAP|0720|LABOR & DELIVERY|Tricare|TRICARE EAST REGION|14,912.25||||||| 59400|EAP|0720|LABOR & DELIVERY|NON CONTRACTED|COMMERCIAL OTHER 1|14,912.25||||||| 59400|EAP|0720|LABOR & DELIVERY LEVEL I|Medicaid|MEDICAID|110.96||||||| 59400|EAP|0720|LABOR & DELIVERY LEVEL I|Medicaid|MOLINA HEALTHCARE OF TEXAS|110.96||||||| 59400|EAP|0720|LABOR & DELIVERY LEVEL I|Managed Medicaid|MEDICAID AMERIGROUP|110.96||||||| 59400|EAP|0720|LABOR & DELIVERY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|14,912.25||||||| 59400|EAP|0720|LABOR & DELIVERY|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|14,912.25||||||| 59400|EAP|0720|LABOR & DELIVERY|Blue Cross HMO Specialty|BCBSTX HMO|14,912.25||||||| 59400|EAP|0720|LABOR & DELIVERY|Blue Cross PPO Specialty|BCBSTX PPO|14,912.25||||||| 59400|EAP|0720|LABOR & DELIVERY LEVEL I|Blue Cross PPO Specialty|BCBSTX PPO|110.96||||||| 59400|EAP|0720|LABOR & DELIVERY|United Healthcare|UNITED HEALTHCARE OTHER|14,912.25||||||| 59400|EAP|0720|LABOR & DELIVERY|United Healthcare|UNITED HEALTHCARE|14,912.25||||||| 59400|EAP|0720|LABOR & DELIVERY LEVEL I|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|110.96||||||| 59400|EAP|0720|LABOR & DELIVERY|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|14,912.25||||||| 59400|EAP|0720|LABOR & DELIVERY|Medicaid|MEDICAID|14,912.25||||||| 59400|EAP|0720|LABOR & DELIVERY LEVEL I|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|110.96||||||| 60100|EAP|0400|US GUIDED BX OF THYROID|Blue Cross PPO Specialty|BCBSTX PPO|||||12.31||| 60100|EAP|0400|US GUIDED BX OF THYROID|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||12.31||| 60100|EAP|0400|US GUIDED BX OF THYROID|United Medicare Advantage|UHC MEDICARE GOLD MA|||||12.31||| 602|DRG||CELLULITIS W MCC|Medicare|MEDICARE ACUTE|59,810.10|12666.84|12666.84|12666.84|||| 603|DRG||CELLULITIS W/O MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|703.82|3223.8|14109.91|3223.8|||| 603|DRG||CELLULITIS W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|47,484.45|3819.32|14109.91|3223.8|||| 603|DRG||CELLULITIS W/O MCC|Humana Medicare Advantage|HUMANA MA|35,676.50|7773.28|14109.91|3223.8|||| 603|DRG||CELLULITIS W/O MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|19,089.25|8513.37|14109.91|3223.8|||| 603|DRG||CELLULITIS W/O MCC|Managed Medicaid|MEDICAID SUPERIOR|104.44|8513.37|14109.91|3223.8|||| 603|DRG||CELLULITIS W/O MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|52,672.30|14109.91|14109.91|3223.8|||| 603|DRG||CELLULITIS W/O MCC|Managed Medicare|HEALTHSPRING MA|30,416.75|8673.95|14109.91|3223.8|||| 603|DRG||CELLULITIS W/O MCC|Medicare|MEDICARE ACUTE|36,357.80|8525.84|14109.91|3223.8|||| 605|DRG||TRAUMA TO THE SKIN, SUBCUT TISS & BREAST W/O MCC|Humana Medicare Advantage|HUMANA MA|43,492.85|8781.39|8781.39|8781.39|||| 62270|EAP|0450|SPINAL TAP DX|Medicaid|MEDICAID|||||805.75||| 62270|EAP|0450|SPINAL TAP DX|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||805.75||| 62270|EAP|0450|SPINAL TAP DX|Managed Medicaid|MEDICAID SUPERIOR|805.75||||||| 62270|EAP|0450|SPINAL TAP DX|Blue Cross HMO Specialty|BCBSTX HMO|805.75||||||| 62270|EAP|0450|SPINAL TAP DX|Blue Cross PPO Specialty|BCBSTX PPO|805.75||||||| 623|DRG||SKIN GRAFTS & WOUND DEBRID FOR ENDOC, NUTRIT & METAB DIS W CC|Medicaid|MEDICAID|604.03|10876.02|10876.02|10876.02|||| 637|DRG||DIABETES W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|941.98|12148.56|52092.55|12148.56|||| 637|DRG||DIABETES W MCC|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|603.14|20198.92|52092.55|12148.56|||| 637|DRG||DIABETES W MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|348.76|15537.64|52092.55|12148.56|||| 637|DRG||DIABETES W MCC|Medicare|MEDICARE ACUTE|36,737.23|12256.755|52092.55|12148.56|||| 637|DRG||DIABETES W MCC|Medicaid|MEDICAID|81,529.48|52092.55|52092.55|12148.56|||| 637|DRG||DIABETES W MCC|Humana Medicare Advantage|HUMANA MA|57,571.10|12194.41|52092.55|12148.56|||| 638|DRG||DIABETES W CC|UTMB|UTMB CORRECTIONAL MANAGED CARE|67,570.88|9679.81|9679.81|8833.04|||| 638|DRG||DIABETES W CC|Humana Medicare Advantage|HUMANA MA|61,389.30|8982.97|9679.81|8833.04|||| 638|DRG||DIABETES W CC|United Healthcare|UNITED HEALTHCARE|44,928.36|8833.04|9679.81|8833.04|||| 638|DRG||DIABETES W CC|Medicare|MEDICARE ACUTE|26,174.10|8948.63|9679.81|8833.04|||| 639|DRG||DIABETES W/O CC/MCC|United Healthcare|TML GROUP BENEFITS|17,173.65|6126.48|7102.8|6126.48|||| 639|DRG||DIABETES W/O CC/MCC|Medicare|MEDICARE ACUTE|15,906.50|7102.8|7102.8|6126.48|||| 639|DRG||DIABETES W/O CC/MCC|Medicare|MEDICARE PART B ONLY IP|30,904.25|6962.14|7102.8|6126.48|||| 64|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC|Managed Medicare|HOSPICE OF EAST TEXAS|3,522.70|15417.34|18731.13|15417.34|||| 64|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC|United Healthcare|UNITED HEALTHCARE|246.51|18731.13|18731.13|15417.34|||| 640|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|34,179.75|10064.71|19370.74|110.02|||| 640|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W MCC|Veterans Affairs|VETERANS ADMINISTRATION|17,862.35|11200.61|19370.74|110.02|||| 640|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|88,034.47|12764.69|19370.74|110.02|||| 640|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|68,348.13|19370.74|19370.74|110.02|||| 640|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W MCC|Managed Medicaid|MEDICAID SUPERIOR|249.02|8437.66|19370.74|110.02|||| 640|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|531.87|12105.24|19370.74|110.02|||| 640|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W MCC|Medicare|MEDICARE ACUTE|39,442.25|110.02|19370.74|110.02|||| 640|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W MCC|Managed Medicare|HOSPICE OF EAST TEXAS|39,346.25|11004.76|19370.74|110.02|||| 640|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W MCC|Rusk State Hospital|RUSK STATE HOSP|19,577.50|9592.98|19370.74|110.02|||| 641|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W/O MCC|Rusk State Hospital|RUSK STATE HOSP|21,576.25|10572.36|10572.36|5154.53|||| 641|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W/O MCC|Medicare|MEDICARE ACUTE|39,044.75|8079.89|10572.36|5154.53|||| 641|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W/O MCC|Humana Medicare Advantage|HUMANA MA|37,034.23|7429.88|10572.36|5154.53|||| 641|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W/O MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|30,442.60|7930.57|10572.36|5154.53|||| 641|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W/O MCC|Managed Medicaid|MEDICAID SUPERIOR|10,284.13|5154.53|10572.36|5154.53|||| 641|DRG||MISC DISORDERS OF NUTRITION, METABOLISM, FLUIDS/ELECTROLYTES W/O MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|23,440.53|8816.395|10572.36|5154.53|||| 643|DRG||ENDOCRINE DISORDERS W MCC|Medicare|MEDICARE ACUTE|330.40|11785.15|11785.15|11785.15|||| 644|DRG||ENDOCRINE DISORDERS W CC|Medicare|MEDICARE ACUTE|239.23|8777.46|8777.46|8777.46|||| 645|DRG||ENDOCRINE DISORDERS W/O CC/MCC|Medicare|MEDICARE ACUTE|26,571.12|8071.185|8071.185|8006.58|||| 645|DRG||ENDOCRINE DISORDERS W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|42,250.25|8006.58|8071.185|8006.58|||| 65|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC OR TPA IN 24 HRS|Humana Medicare Advantage|HUMANA MA|64,653.37|9787.14|9787.14|3922.79|||| 65|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC OR TPA IN 24 HRS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|49,820.30|3922.79|9787.14|3922.79|||| 66|DRG||INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W/O CC/MCC|United Medicare Advantage|AARP UHC WEST COMPLETE MA|25,354.60|7682.78|7682.78|7682.78|||| 682|DRG||RENAL FAILURE W MCC|Managed Medicare|HOSPICE OF EAST TEXAS|9,596.45|12077.75|12998.66|12077.75|||| 682|DRG||RENAL FAILURE W MCC|Medicare|MEDICARE ACUTE|39,633.05|12762.62|12998.66|12077.75|||| 682|DRG||RENAL FAILURE W MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|582.95|12998.66|12998.66|12077.75|||| 682|DRG||RENAL FAILURE W MCC|Humana Medicare Advantage|HUMANA MA|66,894.53|12458.19|12998.66|12077.75|||| 683|DRG||RENAL FAILURE W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|28,600.33|8964.315|34763.42|5842.04|||| 683|DRG||RENAL FAILURE W CC|Rusk State Hospital|RUSK STATE HOSP|70,945.75|34763.42|34763.42|5842.04|||| 683|DRG||RENAL FAILURE W CC|Medicare|MEDICARE ACUTE|25,669.75|8885.96|34763.42|5842.04|||| 683|DRG||RENAL FAILURE W CC|Medicaid|MEDICAID|39,335.80|5842.04|34763.42|5842.04|||| 683|DRG||RENAL FAILURE W CC|Humana Medicare Advantage|HUMANA MA|51,347.53|8988.71|34763.42|5842.04|||| 683|DRG||RENAL FAILURE W CC|Managed Medicaid|MEDICAID SUPERIOR|47,733.25|9288.84|34763.42|5842.04|||| 689|DRG||KIDNEY & URINARY TRACT INFECTIONS W MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|55,549.25|9525.68|10413.11|3846.99|||| 689|DRG||KIDNEY & URINARY TRACT INFECTIONS W MCC|Managed Medicaid|MEDICAID AMERIGROUP|19,349.90|3846.99|10413.11|3846.99|||| 689|DRG||KIDNEY & URINARY TRACT INFECTIONS W MCC|Humana Medicare Advantage|HUMANA MA|1,419.39|10413.11|10413.11|3846.99|||| 689|DRG||KIDNEY & URINARY TRACT INFECTIONS W MCC|Medicare|MEDICARE ACUTE|50,401.18|10339.02|10413.11|3846.99|||| 69|DRG||TRANSIENT ISCHEMIA W/O THROMBOLYTIC|Medicare|MEDICARE ACUTE|34,667.75|8104.7|8104.7|8104.7|||| 690|DRG||KIDNEY & URINARY TRACT INFECTIONS W/O MCC|Managed Medicaid|MEDICAID AMERIGROUP|20,476.95|6905.83|8174.37|3289.96|||| 690|DRG||KIDNEY & URINARY TRACT INFECTIONS W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|25,977.10|3289.96|8174.37|3289.96|||| 690|DRG||KIDNEY & URINARY TRACT INFECTIONS W/O MCC|Managed Medicaid|MEDICAID SUPERIOR|10,331.88|6905.83|8174.37|3289.96|||| 690|DRG||KIDNEY & URINARY TRACT INFECTIONS W/O MCC|Medicare|MEDICARE ACUTE|39,333.40|8174.37|8174.37|3289.96|||| 69200|EAP|0450|RMV FB EXT AUDITORY CANAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||267.75||| 69200|EAP|0450|RMV FB EXT AUDITORY CANAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||267.75||| 69200|EAP|0450|RMV FB EXT AUDITORY CANAL|Medicaid|MEDICAID HMO|||||267.75||| 69200|EAP|0450|RMV FB EXT AUDITORY CANAL|Managed Medicaid|MEDICAID SUPERIOR|||||267.75||| 69209|EAP|0450|REMOVE IMPCTD CERUMEN BY|Medicare|MEDICARE ACUTE|||||2.80||| 69209|EAP|0450|REMOVE IMPCTD CERUMEN BY|Managed Medicaid|MEDICAID AMERIGROUP|||||2.80||| 69209|EAP|0450|REMOVE IMPCTD CERUMEN BY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||2.80||| 69209|EAP|0450|REMOVE IMPCTD CERUMEN BY|Managed Medicaid|MEDICAID SUPERIOR|||||2.80||| 69209|EAP|0450|REMOVE IMPCTD CERUMEN BY|Tricare|TRICARE EAST REGION|||||2.80||| 696|DRG||KIDNEY & URINARY TRACT SIGNS & SYMPTOMS W/O MCC|Humana Medicare Advantage|HUMANA MA|23,766.30|6679.37|6679.37|6679.37|||| 698|DRG||OTHER KIDNEY & URINARY TRACT DIAGNOSES W MCC|Medicare|MEDICARE ACUTE|69,537.78|13701.46|19958.5|13701.46|||| 698|DRG||OTHER KIDNEY & URINARY TRACT DIAGNOSES W MCC|Workers Compensation|WORKERS COMPENSATION OTHER|40,770.15|19958.5|19958.5|13701.46|||| 699|DRG||OTHER KIDNEY & URINARY TRACT DIAGNOSES W CC|United Medicare Advantage|UHC MEDICARE GOLD MA|245.16|9790.25|9963.52|9790.25|||| 699|DRG||OTHER KIDNEY & URINARY TRACT DIAGNOSES W CC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|33,224.15|9963.52|9963.52|9790.25|||| 70110|EAP|0320|XR MANDIBLE|Medicaid|MEDICAID TEXAS CHILDRENS|||||573.75||| 70140|EAP|0320|FACIAL BONES LESS THAN 3|NON CONTRACTED|COMMERCIAL OTHER 1|||||515.75||| 70150|EAP|0320|FACIAL BONES MINIMUM 3 VI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||5.71||| 70150|EAP|0320|FACIAL BONES MINIMUM 3 VI|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||5.71||| 70150|EAP|0320|FACIAL BONES MINIMUM 3 VI|Managed Medicaid|MEDICAID AMERIGROUP|||||5.71||| 70150|EAP|0320|FACIAL BONES MINIMUM 3 VI|Humana Medicare Advantage|HUMANA MA|||||5.71||| 70150|EAP|0320|FACIAL BONES MINIMUM 3 VI|NON CONTRACTED|COMMERCIAL OTHER 1|||||5.71||| 70150|EAP|0320|FACIAL BONES MINIMUM 3 VI|Medicare|MEDICARE ACUTE|||||5.71||| 70150|EAP|0320|FACIAL BONES MINIMUM 3 VI|Medicaid|MEDICAID|||||5.71||| 70160|EAP|0320|XR NASAL BONES|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||573.75||| 70160|EAP|0320|XR NASAL BONES|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||573.75||| 70160|EAP|0320|XR NASAL BONES|Blue Cross PPO Specialty|BCBSTX PPO|||||573.75||| 70160|EAP|0320|XR NASAL BONES|Managed Medicaid|MEDICAID SUPERIOR|||||573.75||| 70160|EAP|0320|XR NASAL BONES|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||573.75||| 70160|EAP|0320|XR NASAL BONES|Medicare|MEDICARE ACUTE|||||573.75||| 70200|EAP|0320|ORBIT|Humana Medicare Advantage|HUMANA MA|||||6.27||| 70200|EAP|0320|ORBIT|Medicare|MEDICARE ACUTE|||||6.27||| 70220|EAP|0320|XR SINUSES 4 VIEWS OR MOR|Humana Medicare Advantage|HUMANA MA|||||573.75||| 70220|EAP|0320|XR SINUSES 4 VIEWS OR MOR|Blue Cross PPO Specialty|BCBSTX PPO|||||573.75||| 70220|EAP|0320|XR SINUSES 4 VIEWS OR MOR|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||573.75||| 70220|EAP|0320|XR SINUSES 4 VIEWS OR MOR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||573.75||| 70220|EAP|0320|XR SINUSES 4 VIEWS OR MOR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||573.75||| 70220|EAP|0320|XR SINUSES 4 VIEWS OR MOR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||573.75||| 70220|EAP|0320|XR SINUSES 4 VIEWS OR MOR|Managed Medicaid|MEDICAID SUPERIOR|||||573.75||| 70220|EAP|0320|XR SINUSES 4 VIEWS OR MOR|Blue Cross HMO Specialty|BCBSTX HMO|||||573.75||| 70220|EAP|0320|XR SINUSES 4 VIEWS OR MOR|Medicare|MEDICARE ACUTE|||||573.75||| 70220|EAP|0320|XR SINUSES 4 VIEWS OR MOR|Blue Cross PPO Specialty|BCBSTX OTHER|||||573.75||| 70250|EAP|0320|XR SKULL 2 VIEWS|Workers Compensation|WORKERS COMPENSATION OTHER|||||573.75||| 70250|EAP|0320|XR SKULL 2 VIEWS|Medicare|MEDICARE ACUTE|||||573.75||| 70250|EAP|0320|XR SKULL 2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||573.75||| 70250|EAP|0320|XR SKULL 2 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|||||573.75||| 70250|EAP|0320|XR SKULL 2 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||573.75||| 70260|EAP|0320|XR SKULL 4 VIEWS OR MORE|Managed Medicaid|MEDICAID SUPERIOR|||||691.50||| 70260|EAP|0320|XR SKULL 4 VIEWS OR MORE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||691.50||| 70260|EAP|0320|XR SKULL 4 VIEWS OR MORE|Blue Cross PPO Specialty|BCBSTX PPO|||||691.50||| 70260|EAP|0320|XR SKULL 4 VIEWS OR MORE|Medicare|MEDICARE ACUTE|||||691.50||| 70260|EAP|0320|XR SKULL 4 VIEWS OR MORE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||691.50||| 70260|EAP|0320|XR SKULL 4 VIEWS OR MORE|Managed Medicaid|MEDICAID AMERIGROUP|||||691.50||| 70260|EAP|0320|XR SKULL 4 VIEWS OR MORE|Medicaid|MEDICAID|||||691.50||| 70360|EAP|0320|XR SOFT TISSUE NECK|Blue Cross PPO Specialty|BCBSTX PPO|||||461.25||| 70360|EAP|0320|XR SOFT TISSUE NECK|Medicare|MEDICARE ACUTE|||||461.25||| 70360|EAP|0320|XR SOFT TISSUE NECK|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||461.25||| 70360|EAP|0320|XR SOFT TISSUE NECK|Managed Medicaid|MEDICAID AMERIGROUP|||||461.25||| 70360|EAP|0320|XR SOFT TISSUE NECK|Managed Medicare|HEALTHSPRING MA|||||461.25||| 70360|EAP|0320|XR SOFT TISSUE NECK|Medicaid|MEDICAID|461.25||||461.25||| 70360|EAP|0320|XR SOFT TISSUE NECK|Managed Medicaid|MEDICAID SUPERIOR|||||461.25||| 70370|EAP|0320|ESOPHAGUS BA SWALLOW W-FL|Medicaid|MEDICAID TEXAS CHILDRENS|||||714.50||| 70370|EAP|0320|ESOPHAGUS BA SWALLOW W-FL|Blue Cross PPO Specialty|BCBSTX PPO|||||714.50||| 70370|EAP|0320|ESOPHAGUS BA SWALLOW W-FL|Humana Medicare Advantage|HUMANA MA|714.50||||714.50||| 70370|EAP|0320|ESOPHAGUS BA SWALLOW W-FL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||714.50||| 70370|EAP|0320|ESOPHAGUS BA SWALLOW W-FL|United Healthcare|UNITED HEALTHCARE OTHER|||||714.50||| 70370|EAP|0320|ESOPHAGUS BA SWALLOW W-FL|Medicare|MEDICARE ACUTE|714.50||||714.50||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|Blue Cross PPO Specialty|BCBSTX OTHER|||||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|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3,627.75||||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|Humana Medicare Advantage|HUMANA 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|Access Direct Platinum|HEALTHFIRST TPA UMR|||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|Aetna|AETNA PPO|3,627.75||||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|United Medicare Advantage|AARP UHC WEST COMPLETE 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|Veterans Affairs|VETERANS ADMINISTRATION|||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|United Healthcare|TML GROUP BENEFITS|||||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|United Healthcare|UNITED HEALTHCARE OTHER|||||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 CIGNA HEALTHSPRING|3,627.75||||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|Managed Medicaid|MEDICAID AMERIGROUP|||||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|Managed Medicaid|MEDICAID SUPERIOR|3,627.75||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3,627.75||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|Medicaid|MEDICAID|3,627.75||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|Cigna|CIGNA|||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|Medicaid|MEDICAID HMO|||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|PHCS|HUMANA INSURANCE|||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|United Healthcare|UNITED HEALTHCARE|3,627.75||||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|Medicare|MEDICARE ACUTE|3,627.75||||3,627.75||| 70450|EAP|0350|HEAD SCAN W/O CONTRAST|Tricare|TRICARE FOR LIFE|||||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|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||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|Rusk State Hospital|RUSK STATE HOSP|3,627.75||||3,627.75||| 70460|EAP|0350|HEAD SCAN W/CONTRAST|Medicare|MEDICARE ACUTE|4,738.75||||||| 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||||||| 70470|EAP|0350|HEAD SCAN W&W/O CONTRAST|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||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||| 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|Cigna|CIGNA|||||3,627.75||| 70480|EAP|0350|INT AUD CANAL AXIAL W/O C|Blue Cross PPO Specialty|BCBSTX PPO|||||3,627.75||| 70480|EAP|0350|INT AUD CANAL AXIAL W/O C|Humana Medicare Advantage|HUMANA MA|||||3,627.75||| 70480|EAP|0350|INT AUD CANAL AXIAL W/O C|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||3,627.75||| 70486|EAP|0351|FACIAL BONES/SINUSES W/O|Access Direct Platinum|HEALTHFIRST TPA UMR|||||3,627.75||| 70486|EAP|0351|FACIAL BONES/SINUSES W/O|Blue Cross HMO Specialty|BCBSTX HMO|||||3,627.75||| 70486|EAP|0351|FACIAL BONES/SINUSES W/O|Aetna|AETNA PPO|||||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|Blue Cross PPO Specialty|BCBSTX PPO|||||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|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||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 MEDICARE GOLD MA|||||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|Workers Compensation|WORKERS COMPENSATION OTHER|||||3,627.75||| 70486|EAP|0351|FACIAL BONES/SINUSES W/O|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||3,627.75||| 70486|EAP|0351|FACIAL BONES/SINUSES W/O|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||3,627.75||| 70486|EAP|0351|FACIAL BONES/SINUSES W/O|Managed Medicaid|MEDICAID SUPERIOR|||||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|Managed Medicaid|MEDICAID AMERIGROUP|||||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|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||3,627.75||| 70486|EAP|0351|FACIAL BONES/SINUSES W/O|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||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|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||3,627.75||| 70486|EAP|0351|FACIAL BONES/SINUSES W/O|Tricare|TRICARE EAST REGION|||||3,627.75||| 70486|EAP|0351|FACIAL BONES/SINUSES W/O|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||3,627.75||| 70486|EAP|0351|FACIAL BONES/SINUSES W/O|Medicare|MEDICARE ACUTE|3,627.75||||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 Medicaid|MEDICAID UNITED HEALTHCARE|||||3,627.75||| 70486|EAP|0351|FACIAL BONES/SINUSES W/O|Cigna|CIGNA|||||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|Rusk State Hospital|RUSK STATE HOSP|||||3,627.75||| 70486|EAP|0351|FACIAL BONES/SINUSES W/O|Medicaid|MEDICAID|||||3,627.75||| 70487|EAP|0350|FACIAL BONES/SINUSES W/CO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||4,738.75||| 70487|EAP|0350|FACIAL BONES/SINUSES W/CO|Managed Medicaid|MEDICAID AMERIGROUP|||||4,738.75||| 70487|EAP|0350|FACIAL BONES/SINUSES W/CO|Managed Medicaid|MEDICAID SUPERIOR|||||4,738.75||| 70488|EAP|0350|FACIAL BONES/SINUSES W&W/|Medicare|MEDICARE ACUTE|||||53.74||| 70488|EAP|0350|FACIAL BONES/SINUSES W&W/|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||53.74||| 70490|EAP|0350|SOFT TISSUE NECK CT W/O C|Blue Cross PPO Specialty|BCBSTX OTHER|||||3,627.75||| 70490|EAP|0350|SOFT TISSUE NECK CT W/O C|Blue Cross HMO Specialty|BCBSTX HMO|||||3,627.75||| 70490|EAP|0350|SOFT TISSUE NECK CT W/O C|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||3,627.75||| 70490|EAP|0350|SOFT TISSUE NECK CT W/O C|Managed Medicare|HEALTHSPRING MA|||||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 CIGNA HEALTHSPRING|||||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|Humana Medicare Advantage|HUMANA MA|||||3,627.75||| 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|Medicare|MEDICARE ACUTE|4,738.75||||4,738.75||| 70491|EAP|0350|SOFT TISSUE CT NECK W CON|Managed Medicare|HEALTHSPRING MA|||||4,738.75||| 70491|EAP|0350|SOFT TISSUE CT NECK W CON|Managed Medicaid|MEDICAID SUPERIOR|4,738.75||||4,738.75||| 70491|EAP|0350|SOFT TISSUE CT NECK W CON|Managed Medicaid|MEDICAID AMERIGROUP|||||4,738.75||| 70491|EAP|0350|SOFT TISSUE CT NECK W CON|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4,738.75||||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|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP 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|Blue Cross PPO Specialty|BCBSTX PPO|||||4,738.75||| 70491|EAP|0350|SOFT TISSUE CT NECK W CON|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||4,738.75||| 70491|EAP|0350|SOFT TISSUE CT NECK W CON|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||4,738.75||| 70491|EAP|0350|SOFT TISSUE CT NECK W CON|Humana Medicare Advantage|HUMANA MA|4,738.75||||4,738.75||| 70496|EAP|0350|CT ANGIO HEAD|Humana Medicare Advantage|HUMANA MA|3,394.25||||3,394.25||| 70496|EAP|0350|CT ANGIO HEAD|Aenta Medicare Advantage|AETNA MEDICARE MA|||||3,394.25||| 70496|EAP|0350|CT ANGIO HEAD|Blue Cross HMO Specialty|BCBSTX HMO|||||3,394.25||| 70496|EAP|0350|CT ANGIO HEAD|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||3,394.25||| 70496|EAP|0350|CT ANGIO HEAD|United Healthcare|UNITED HEALTHCARE OTHER|||||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|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||3,394.25||| 70496|EAP|0350|CT ANGIO HEAD|Medicare|MEDICARE ACUTE|3,394.25||||3,394.25||| 70498|EAP|0350|CT ANGIO NECK|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||3,300.50||| 70498|EAP|0350|CT ANGIO NECK|Managed Medicare|HEALTHSPRING 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|United Healthcare|UNITED HEALTHCARE OTHER|||||3,300.50||| 70498|EAP|0350|CT ANGIO NECK|Medicare|MEDICARE ACUTE|3,300.50||||3,300.50||| 70498|EAP|0350|CT ANGIO NECK|Aenta Medicare Advantage|AETNA MEDICARE MA|||||3,300.50||| 70498|EAP|0350|CT ANGIO NECK|Aetna|AETNA OTHER|3,300.50||||||| 70498|EAP|0350|CT ANGIO NECK|Blue Cross HMO Specialty|BCBSTX HMO|||||3,300.50||| 70498|EAP|0350|CT ANGIO NECK|Blue Cross PPO Specialty|BCBSTX PPO|||||3,300.50||| 70498|EAP|0350|CT ANGIO NECK|Humana Medicare Advantage|HUMANA MA|||||3,300.50||| 70540|EAP|0611|MRI ORBITS FACE NECK W/O|Medicare|MEDICARE ACUTE|||||58.50||| 70540|EAP|0611|MRI ORBITS FACE NECK W/O|Tricare|TRICARE EAST REGION|||||58.50||| 70540|EAP|0611|MRI ORBITS FACE NECK W/O|Blue Cross PPO Specialty|BCBSTX PPO|||||58.50||| 70543|EAP|0612|MRI ORBIT/FACE/NECK W/WO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||7,914.25||| 70543|EAP|0612|MRI ORBIT/FACE/NECK W/WO|Blue Cross HMO Specialty|BCBSTX HMO|||||7,914.25||| 70543|EAP|0610|MRI NECK SOFT TISSUE W&W/|Humana Medicare Advantage|HUMANA MA|7,914.25||||7,914.25||| 70543|EAP|0610|MRI NECK SOFT TISSUE W&W/|Blue Cross PPO Specialty|BCBSTX PPO|||||7,914.25||| 70544|EAP|0610|MRA HEAD W/0 CONTRAST|Medicare|MEDICARE ACUTE|||||58.50||| 70544|EAP|0610|MRA HEAD W/0 CONTRAST|Humana Medicare Advantage|HUMANA MA|58.50||||58.50||| 70544|EAP|0610|MRA HEAD W/0 CONTRAST|Blue Cross PPO Specialty|BCBSTX PPO|||||58.50||| 70544|EAP|0610|MRA HEAD W/0 CONTRAST|Blue Cross HMO Specialty|BCBSTX HMO|||||58.50||| 70544|EAP|0610|MRA HEAD W/0 CONTRAST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|58.50||||58.50||| 70547|EAP|0610|MRA NECK W/O CONTRAST|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||58.50||| 70547|EAP|0610|MRA NECK W/O CONTRAST|Humana Medicare Advantage|HUMANA MA|||||58.50||| 70547|EAP|0610|MRA NECK W/O CONTRAST|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||58.50||| 70547|EAP|0610|MRA NECK W/O CONTRAST|Medicare|MEDICARE ACUTE|||||58.50||| 70551|EAP|0611|MRI BRAIN W/O CONTRAST|Medicaid|MEDICAID|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|Medicare|MEDICARE ACUTE|58.50||||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 CIGNA HEALTHSPRING|||||58.50||| 70551|EAP|0611|MRI BRAIN W/O CONTRAST|United Medicare Advantage|UHC MEDICARE GOLD MA|||||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|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||58.50||| 70551|EAP|0611|MRI BRAIN W/O CONTRAST|Blue Cross PPO Specialty|BCBSTX PPO|||||58.50||| 70551|EAP|0611|MRI BRAIN W/O CONTRAST|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||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|Blue Cross HMO Specialty|BCBSTX HMO|||||58.50||| 70551|EAP|0611|MRI BRAIN W/O CONTRAST|Access Direct Platinum|HEALTHFIRST TPA UMR|||||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|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|58.50||||58.50||| 70551|EAP|0611|MRI BRAIN W/O CONTRAST|United Healthcare|TML GROUP BENEFITS|||||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|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||58.50||| 70551|EAP|0611|MRI BRAIN W/O CONTRAST|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||58.50||| 70551|EAP|0611|MRI BRAIN W/O CONTRAST|Managed Medicaid|MEDICAID SUPERIOR|||||58.50||| 70552|EAP|0611|MRI BRAIN WITH CONTRAST|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||6,961.50||| 70553|EAP|0611|MRI BRAIN W/WO CONTRAST|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||7,914.25||| 70553|EAP|0611|MRI BRAIN W/WO CONTRAST|Medicare|MEDICARE ACUTE|7,914.25||||7,914.25||| 70553|EAP|0611|MRI BRAIN W/WO CONTRAST|Medicaid|MEDICAID|7,914.25||||||| 70553|EAP|0611|MRI BRAIN W/WO CONTRAST|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||7,914.25||| 70553|EAP|0611|MRI BRAIN W/WO CONTRAST|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||7,914.25||| 70553|EAP|0611|MRI BRAIN W/WO CONTRAST|Managed Medicaid|MEDICAID AMERIGROUP|||||7,914.25||| 70553|EAP|0611|MRI BRAIN W/WO CONTRAST|NON CONTRACTED|COMMERCIAL OTHER 1|||||7,914.25||| 70553|EAP|0611|MRI BRAIN W/WO CONTRAST|United Healthcare|TML GROUP BENEFITS|||||7,914.25||| 70553|EAP|0611|MRI BRAIN W/WO CONTRAST|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||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|Humana Medicare Advantage|HUMANA MA|||||7,914.25||| 70553|EAP|0611|MRI BRAIN W/WO CONTRAST|Cigna|CIGNA|||||7,914.25||| 70553|EAP|0611|MRI BRAIN W/WO CONTRAST|Blue Cross PPO Specialty|BCBSTX OTHER|||||7,914.25||| 70553|EAP|0611|MRI BRAIN W/WO CONTRAST|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||7,914.25||| 70553|EAP|0611|MRI BRAIN W/WO CONTRAST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7,914.25||||7,914.25||| 70553|EAP|0611|MRI BRAIN W/WO CONTRAST|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||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|Blue Cross HMO Specialty|BCBSTX HMO|||||7,914.25||| 70553|EAP|0611|MRI BRAIN W/WO CONTRAST|Blue Cross PPO Specialty|BCBSTX PPO|||||7,914.25||| 71045|EAP|0324|CHEST 1 VIEW|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|452.25||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|Aetna|AETNA OTHER|452.25||||||| 71045|EAP|0324|CHEST 1 VIEW|Aetna|AETNA PPO|452.25||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|Aenta Medicare Advantage|AETNA MEDICARE MA|452.25||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|452.25||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|452.25||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|Blue Cross PPO Specialty|BCBSTX PPO|452.25||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|Cigna|CIGNA|452.25||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|452.25||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|Cigna|CIGNA|||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|Blue Cross PPO Specialty|BCBSTX OTHER|452.25||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|Workers Compensation|WORKERS COMPENSATION OTHER|||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|United Healthcare|TML GROUP BENEFITS|452.25||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|452.25||||||| 71045|EAP|0324|CHEST 1 VIEW|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|Veterans Affairs|VETERANS ADMINISTRATION|452.25||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|UTMB|UTMB CORRECTIONAL MANAGED CARE|452.25||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|Rusk State Hospital|RUSK STATE HOSP|452.25||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|Medicaid|COUNTY INDIGENT HEALTH OTHER|452.25||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|Medicaid|SUPERIOR HEALTHPLAN CHIP|452.25||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|Medicaid|MEDICAID|452.25||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|Workers Compensation|UT EMPLOYEE INJURY|452.25||||||| 71045|EAP|0324|CHEST 1 VIEW|Medicaid|MEDICAID PCCM|||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|NON CONTRACTED|COMMERCIAL OTHER 2|||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|United Healthcare|UNITED HEALTHCARE|452.25||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|Tricare|TRICARE EAST REGION|||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|United Healthcare|UNITED HEALTHCARE OTHER|||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|Medicaid|MEDICAID TEXAS CHILDRENS|||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|Humana Medicare Advantage|HUMANA MA|452.25||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|Medicare|MEDICARE PART B ONLY IP|452.25||||||| 71045|EAP|0324|CHEST 1 VIEW|United Medicare Advantage|UHC MEDICARE GOLD MA|452.25||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|Medicaid|MEDICAID HMO|||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|NON CONTRACTED|COMMERCIAL OTHER 1|452.25||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|United Healthcare|GEHA|||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|Medicare|MEDICARE ACUTE|452.25||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|United Medicare Advantage|AARP UHC WEST COMPLETE MA|452.25||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|452.25||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|PHCS|HUMANA INSURANCE|||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|Access Direct Platinum|HEALTHFIRST TPA UMR|||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|Blue Cross HMO Specialty|BCBSTX HMO|452.25||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|Managed Medicaid|MEDICAID UNITED HEALTHCARE|452.25||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|452.25||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|452.25||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|Managed Medicaid|MEDICAID SUPERIOR|452.25||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|Managed Medicare|HEALTHSPRING MA|452.25||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|Managed Medicare|HOSPICE OF EAST TEXAS|452.25||||||| 71045|EAP|0324|CHEST 1 VIEW|Managed Medicaid|MEDICAID AMERIGROUP|452.25||||452.25||| 71045|EAP|0324|CHEST 1 VIEW|Managed Medicare|BCBS MEDICARE PPO MA|||||452.25||| 71046|EAP|0324|CHEST 2 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|515.75||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|Managed Medicare|HEALTHSPRING MA|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|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|515.75||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|Managed Medicare|BCBS MEDICARE PPO MA|||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|515.75||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|Medicaid|MEDICAID|515.75||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|UTMB|UTMB CORRECTIONAL MANAGED CARE|515.75||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|Tricare|TRICARE EAST REGION|515.75||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|Medicare|MEDICARE ACUTE|515.75||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|Medicaid|MEDICAID HMO|||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|Veterans Affairs|VETERANS ADMINISTRATION|515.75||||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|United Healthcare|UNITED HEALTHCARE OTHER|515.75||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|Medicaid|MEDICAID TEXAS CHILDRENS|||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|515.75||||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|Workers Compensation|WORKERS COMPENSATION OTHER|515.75||||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|||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|United Healthcare|UNITED HEALTHCARE|515.75||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|515.75||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|515.75||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||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 PPO Specialty|BCBSTX OTHER|515.75||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|Aetna|AETNA OTHER|||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|515.75||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|515.75||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|Access Direct Platinum|HEALTHFIRST TPA UMR|||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|Aetna|AETNA PPO|515.75||||515.75||| 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|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|515.75||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|515.75||||515.75||| 71046|EAP|0324|CHEST 2 VIEWS|Aenta Medicare Advantage|AETNA MEDICARE MA|515.75||||515.75||| 71101|EAP|0320|RIBS LT.W/CXR 1 VIEW|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||5.71||| 71101|EAP|0320|RIBS LT.W/CXR 1 VIEW|Blue Cross HMO Specialty|BCBSTX HMO|||||5.71||| 71101|EAP|0320|RIBS LT.W/CXR 1 VIEW|Aenta Medicare Advantage|AETNA MEDICARE MA|||||5.71||| 71101|EAP|0320|RIBS LT.W/CXR 1 VIEW|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||5.71||| 71101|EAP|0320|RIBS LT.W/CXR 1 VIEW|Humana Medicare Advantage|HUMANA MA|5.71||||5.71||| 71101|EAP|0320|RIB RT. W/CXR 1 VIEW|Blue Cross PPO Specialty|BCBSTX PPO|||||5.71||| 71101|EAP|0320|RIB RT. W/CXR 1 VIEW|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||5.71||| 71101|EAP|0320|RIB RT. W/CXR 1 VIEW|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.71||||5.71||| 71101|EAP|0320|RIBS LT.W/CXR 1 VIEW|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||5.71||| 71101|EAP|0320|RIBS LT.W/CXR 1 VIEW|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.71||||5.71||| 71101|EAP|0320|RIB RT. W/CXR 1 VIEW|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||5.71||| 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|||||5.71||| 71101|EAP|0320|RIB RT. W/CXR 1 VIEW|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||5.71||| 71101|EAP|0320|RIB RT. W/CXR 1 VIEW|Medicare|MEDICARE ACUTE|5.71||||5.71||| 71101|EAP|0320|RIB RT. W/CXR 1 VIEW|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||5.71||| 71101|EAP|0320|RIBS LT.W/CXR 1 VIEW|Medicare|MEDICARE ACUTE|5.71||||5.71||| 71101|EAP|0320|RIB RT. W/CXR 1 VIEW|Humana Medicare Advantage|HUMANA MA|5.71||||5.71||| 71101|EAP|0320|RIBS LT.W/CXR 1 VIEW|Managed Medicaid|MEDICAID SUPERIOR|||||5.71||| 71101|EAP|0320|RIBS LT.W/CXR 1 VIEW|Blue Cross PPO Specialty|BCBSTX PPO|||||5.71||| 71101|EAP|0320|RIB RT. W/CXR 1 VIEW|Managed Medicaid|MEDICAID SUPERIOR|||||5.71||| 71101|EAP|0320|RIBS LT.W/CXR 1 VIEW|Managed Medicaid|MEDICAID AMERIGROUP|||||5.71||| 71101|EAP|0320|RIB RT. W/CXR 1 VIEW|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||5.71||| 71101|EAP|0320|RIBS LT.W/CXR 1 VIEW|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||5.71||| 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|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||5.71||| 71101|EAP|0320|RIBS LT.W/CXR 1 VIEW|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||5.71||| 71111|EAP|0320|RIBS BILAT W PA CHEST|Managed Medicaid|MEDICAID AMERIGROUP|||||654.50||| 71111|EAP|0320|RIBS BILAT W PA CHEST|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||654.50||| 71111|EAP|0320|RIBS BILAT W PA CHEST|Medicare|MEDICARE ACUTE|||||654.50||| 71111|EAP|0320|RIBS BILAT W PA CHEST|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||654.50||| 71111|EAP|0320|RIBS BILAT W PA CHEST|Workers Compensation|WORKERS COMPENSATION OTHER|||||654.50||| 71111|EAP|0320|RIBS BILAT W PA CHEST|Humana Medicare Advantage|HUMANA MA|||||654.50||| 71111|EAP|0320|RIBS BILAT W PA CHEST|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||654.50||| 71111|EAP|0320|RIBS BILAT W PA CHEST|Blue Cross HMO Specialty|BCBSTX HMO|||||654.50||| 71111|EAP|0320|RIBS BILAT W PA CHEST|Aenta Medicare Advantage|AETNA MEDICARE MA|||||654.50||| 71111|EAP|0320|RIBS BILAT W PA CHEST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||654.50||| 71111|EAP|0320|RIBS BILAT W PA CHEST|NON CONTRACTED|COMMERCIAL OTHER 1|||||654.50||| 71111|EAP|0320|RIBS BILAT W PA CHEST|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||654.50||| 71111|EAP|0320|RIBS BILAT W PA CHEST|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||654.50||| 71120|EAP|0320|STERNUM 2 VIEWS|Humana Medicare Advantage|HUMANA MA|||||515.75||| 71120|EAP|0320|STERNUM 2 VIEWS|Blue Cross PPO Specialty|BCBSTX OTHER|||||515.75||| 71130|EAP|0320|STERNOCLAVICULAR JOINTS|Medicare|MEDICARE ACUTE|||||5.71||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|Veterans Affairs|VETERANS ADMINISTRATION|||||3,627.75||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|United Healthcare|UNITED HEALTHCARE OTHER|||||3,627.75||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||3,627.75||| 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|AARP UHC WEST COMPLETE MA|3,627.75||||3,627.75||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||3,627.75||| 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|Aenta Medicare Advantage|AETNA MEDICARE MA|3,627.75||||3,627.75||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|Blue Cross HMO Specialty|BCBSTX HMO|||||3,627.75||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||3,627.75||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3,627.75||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|Blue Cross PPO Specialty|BCBSTX OTHER|3,627.75||||3,627.75||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|Cigna|CIGNA|||||3,627.75||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|Blue Cross PPO Specialty|BCBSTX PPO|||||3,627.75||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|Humana Medicare Advantage|HUMANA MA|3,627.75||||3,627.75||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|United Medicare Advantage|UHC MEDICARE GOLD MA|3,627.75||||3,627.75||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|Managed Medicaid|MEDICAID SUPERIOR|||||3,627.75||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|Managed Medicare|HEALTHSPRING MA|||||3,627.75||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|Managed Medicaid|MEDICAID AMERIGROUP|||||3,627.75||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|Managed Medicaid|MEDICAID 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||||3,627.75||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3,627.75||||3,627.75||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3,627.75||||3,627.75||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|Medicare|MEDICARE ACUTE|3,627.75||||3,627.75||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|Rusk State Hospital|RUSK STATE HOSP|||||3,627.75||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|NON CONTRACTED|COMMERCIAL OTHER 1|||||3,627.75||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|UTMB|UTMB CORRECTIONAL MANAGED CARE|3,627.75||||3,627.75||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|Medicaid|MEDICAID HMO|||||3,627.75||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|Medicare|MEDICARE PART B ONLY IP|||||3,627.75||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|Tricare|TRICARE EAST REGION|||||3,627.75||| 71250|EAP|0350|CHEST W/O CONTRAST E1M1|Medicaid|MEDICAID|||||3,627.75||| 71260|EAP|0350|CHEST W CONTRAST E1M1|Medicaid|MEDICAID|4,738.75||||4,738.75||| 71260|EAP|0350|CHEST W CONTRAST E1M1|Tricare|TRICARE EAST REGION|||||4,738.75||| 71260|EAP|0350|CHEST W CONTRAST E1M1|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||4,738.75||| 71260|EAP|0350|CHEST W CONTRAST E1M1|Medicare|MEDICARE ACUTE|4,738.75||||4,738.75||| 71260|EAP|0350|CHEST W CONTRAST E1M1|NON CONTRACTED|COMMERCIAL OTHER 1|4,738.75||||4,738.75||| 71260|EAP|0350|CHEST W CONTRAST E1M1|Managed Medicare|BCBS MEDICARE PPO MA|||||4,738.75||| 71260|EAP|0350|CHEST W CONTRAST E1M1|Managed Medicaid|MEDICAID AMERIGROUP|||||4,738.75||| 71260|EAP|0350|CHEST W CONTRAST E1M1|Managed Medicaid|MEDICAID SUPERIOR|||||4,738.75||| 71260|EAP|0350|CHEST W CONTRAST E1M1|Cigna|CIGNA|||||4,738.75||| 71260|EAP|0350|CHEST W CONTRAST E1M1|Humana Medicare Advantage|HUMANA MA|4,738.75||||4,738.75||| 71260|EAP|0350|CHEST W CONTRAST E1M1|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||4,738.75||| 71260|EAP|0350|CHEST W CONTRAST E1M1|Blue Cross PPO Specialty|BCBSTX OTHER|||||4,738.75||| 71260|EAP|0350|CHEST W CONTRAST E1M1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||4,738.75||| 71260|EAP|0350|CHEST W CONTRAST E1M1|Blue Cross PPO Specialty|BCBSTX PPO|4,738.75||||4,738.75||| 71260|EAP|0350|CHEST W CONTRAST E1M1|Managed Medicare|HEALTHSPRING MA|||||4,738.75||| 71260|EAP|0350|CHEST W CONTRAST E1M1|Blue Cross HMO Specialty|BCBSTX HMO|||||4,738.75||| 71260|EAP|0350|CHEST W CONTRAST E1M1|Aetna|AETNA PPO|4,738.75||||4,738.75||| 71260|EAP|0350|CHEST W CONTRAST E1M1|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||4,738.75||| 71260|EAP|0350|CHEST W CONTRAST E1M1|Aenta Medicare Advantage|AETNA MEDICARE MA|||||4,738.75||| 71260|EAP|0350|CHEST W CONTRAST E1M1|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||4,738.75||| 71260|EAP|0350|CHEST W CONTRAST E1M1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||4,738.75||| 71260|EAP|0350|CHEST W CONTRAST E1M1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||4,738.75||| 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|Workers Compensation|WORKERS COMPENSATION OTHER|||||4,738.75||| 71260|EAP|0350|CHEST W CONTRAST E1M1|United Medicare Advantage|UHC MEDICARE GOLD MA|4,738.75||||4,738.75||| 71260|EAP|0350|CHEST W CONTRAST E1M1|Veterans Affairs|VETERANS ADMINISTRATION|4,738.75||||4,738.75||| 71260|EAP|0350|CHEST W CONTRAST E1M1|United Healthcare|UNITED HEALTHCARE|||||4,738.75||| 71260|EAP|0350|CHEST W CONTRAST E1M1|Rusk State Hospital|RUSK STATE HOSP|4,738.75||||||| 71260|EAP|0350|CHEST W CONTRAST E1M1|United Healthcare|TML GROUP BENEFITS|||||4,738.75||| 71260|EAP|0350|CHEST W CONTRAST E1M1|United Healthcare|UNITED HEALTHCARE OTHER|||||4,738.75||| 71260|EAP|0350|CHEST W CONTRAST E1M1|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||4,738.75||| 71270|EAP|0350|CHEST W&W/O CONTRAST E|Blue Cross PPO Specialty|BCBSTX PPO|53.74||||||| 71270|EAP|0350|CHEST W&W/O CONTRAST E|Humana Medicare Advantage|HUMANA MA|53.74||||53.74||| 71270|EAP|0350|CHEST W&W/O CONTRAST E|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||53.74||| 71270|EAP|0350|CHEST W&W/O CONTRAST E|Medicare|MEDICARE ACUTE|||||53.74||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|Managed Medicaid|MEDICAID SUPERIOR|3,668.75||||3,668.75||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|Managed Medicaid|MEDICAID AMERIGROUP|||||3,668.75||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|Managed Medicare|HEALTHSPRING MA|3,668.75||||||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|Managed Medicaid|MEDICAID UNITED HEALTHCARE|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|Medicaid|MEDICAID|3,668.75||||||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|Rusk State Hospital|RUSK STATE HOSP|3,668.75||||||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|Medicare|MEDICARE ACUTE|3,668.75||||3,668.75||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|Tricare|TRICARE EAST REGION|||||3,668.75||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|Veterans Affairs|VETERANS ADMINISTRATION|||||3,668.75||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3,668.75||||3,668.75||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|United Medicare Advantage|UHC MEDICARE GOLD MA|3,668.75||||3,668.75||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|NON CONTRACTED|COMMERCIAL OTHER 1|3,668.75||||||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||3,668.75||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|United Medicare Advantage|AARP UHC WEST COMPLETE MA|3,668.75||||3,668.75||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|United Healthcare|UNITED HEALTHCARE|3,668.75||||||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|Humana Medicare Advantage|HUMANA MA|3,668.75||||3,668.75||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3,668.75||||3,668.75||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|Blue Cross PPO Specialty|BCBSTX OTHER|3,668.75||||||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|Cigna|CIGNA|3,668.75||||3,668.75||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|Blue Cross PPO Specialty|BCBSTX PPO|||||3,668.75||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||3,668.75||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3,668.75||||3,668.75||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3,668.75||||||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||3,668.75||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|Aetna|AETNA OTHER|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|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3,668.75||||||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|Aenta Medicare Advantage|AETNA MEDICARE MA|3,668.75||||3,668.75||| 71275|EAP|0350|CT ANGIO CHEST (NON CORON|Aetna|AETNA PPO|||||3,668.75||| 72020|EAP|0320|XR SPINE CERVICAL 1 VIEW|Cigna|CIGNA|||||393.75||| 72020|EAP|0320|XR SPINE CERVICAL 1 VIEW|Workers Compensation|WORKERS COMPENSATION OTHER|||||393.75||| 72040|EAP|0320|SPINE CERVICAL 3VIEW OR L|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||515.75||| 72040|EAP|0320|SPINE CERVICAL 3VIEW OR L|Medicare|MEDICARE ACUTE|||||515.75||| 72040|EAP|0320|SPINE CERVICAL 3VIEW OR L|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||515.75||| 72040|EAP|0320|SPINE CERVICAL 3VIEW OR L|NON CONTRACTED|COMMERCIAL OTHER 1|||||515.75||| 72040|EAP|0320|SPINE CERVICAL 3VIEW OR L|Managed Medicare|BCBS MEDICARE PPO MA|||||515.75||| 72040|EAP|0320|SPINE CERVICAL 3VIEW OR L|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||515.75||| 72040|EAP|0320|SPINE CERVICAL 3VIEW OR L|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||515.75||| 72040|EAP|0320|SPINE CERVICAL 3VIEW OR L|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||515.75||| 72040|EAP|0320|SPINE CERVICAL 3VIEW OR L|Managed Medicaid|MEDICAID AMERIGROUP|||||515.75||| 72040|EAP|0320|SPINE CERVICAL 3VIEW OR L|Managed Medicaid|MEDICAID SUPERIOR|||||515.75||| 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 Healthcare|UNITED HEALTHCARE|||||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|Medicaid|MEDICAID|||||515.75||| 72040|EAP|0320|SPINE CERVICAL 3VIEW OR L|Aenta Medicare Advantage|AETNA MEDICARE MA|||||515.75||| 72040|EAP|0320|SPINE CERVICAL 3VIEW OR L|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||515.75||| 72040|EAP|0320|SPINE CERVICAL 3VIEW OR L|Aetna|AETNA OTHER|||||515.75||| 72040|EAP|0320|SPINE CERVICAL 3VIEW OR L|Blue Cross HMO Specialty|BCBSTX HMO|||||515.75||| 72040|EAP|0320|SPINE CERVICAL 3VIEW OR L|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||515.75||| 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 Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||515.75||| 72040|EAP|0320|SPINE CERVICAL 3VIEW OR L|Cigna|CIGNA|||||515.75||| 72040|EAP|0320|SPINE CERVICAL 3VIEW OR L|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||515.75||| 72040|EAP|0320|SPINE CERVICAL 3VIEW OR L|Humana Medicare Advantage|HUMANA MA|||||515.75||| 72040|EAP|0320|SPINE CERVICAL 3VIEW OR L|Blue Cross PPO Specialty|BCBSTX PPO|||||515.75||| 72050|EAP|0320|SPINE CERVICAL 6 MOS OR M|Blue Cross PPO Specialty|BCBSTX PPO|||||742.50||| 72050|EAP|0320|SPINE CERVICAL 6 MOS OR M|Aenta Medicare Advantage|AETNA MEDICARE MA|||||742.50||| 72050|EAP|0320|SPINE CERVICAL 6 MOS OR M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||742.50||| 72050|EAP|0320|SPINE CERVICAL 6 MOS OR M|Workers Compensation|WORKERS COMPENSATION OTHER|||||742.50||| 72050|EAP|0320|SPINE CERVICAL 4 OR 5 VIE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||663.50||| 72050|EAP|0320|SPINE CERVICAL 4 OR 5 VIE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||663.50||| 72050|EAP|0320|SPINE CERVICAL 6 MOS OR M|Managed Medicaid|MEDICAID SUPERIOR|||||742.50||| 72050|EAP|0320|SPINE CERVICAL 6 MOS OR M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||742.50||| 72050|EAP|0320|SPINE CERVICAL 4 OR 5 VIE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||663.50||| 72050|EAP|0320|SPINE CERVICAL 6 MOS OR M|Medicaid|MEDICAID|||||742.50||| 72050|EAP|0320|SPINE CERVICAL 4 OR 5 VIE|Humana Medicare Advantage|HUMANA MA|||||663.50||| 72050|EAP|0320|SPINE CERVICAL 4 OR 5 VIE|Medicare|MEDICARE ACUTE|||||663.50||| 72050|EAP|0320|SPINE CERVICAL 6 MOS OR M|Medicare|MEDICARE ACUTE|||||742.50||| 72050|EAP|0320|SPINE CERVICAL 4 OR 5 VIE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||663.50||| 72072|EAP|0320|XR SPINE THORACIC 3 VIEWS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||563.50||| 72072|EAP|0320|XR SPINE THORACIC 3 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|||||563.50||| 72072|EAP|0320|XR SPINE THORACIC 3 VIEWS|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||563.50||| 72072|EAP|0320|XR SPINE THORACIC 3 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||563.50||| 72072|EAP|0320|XR SPINE THORACIC 3 VIEWS|Medicare|MEDICARE ACUTE|||||563.50||| 72072|EAP|0320|XR SPINE THORACIC 3 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||563.50||| 72072|EAP|0320|XR SPINE THORACIC 3 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||563.50||| 72072|EAP|0320|XR SPINE THORACIC 3 VIEWS|Managed Medicare|HEALTHSPRING MA|||||563.50||| 72072|EAP|0320|XR SPINE THORACIC 3 VIEWS|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||563.50||| 72072|EAP|0320|XR SPINE THORACIC 3 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||563.50||| 72072|EAP|0320|XR SPINE THORACIC 3 VIEWS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||563.50||| 72072|EAP|0320|XR SPINE THORACIC 3 VIEWS|United Healthcare|TML GROUP BENEFITS|||||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|Blue Cross HMO Specialty|BCBSTX HMO|||||563.50||| 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|Humana Medicare Advantage|HUMANA MA|||||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|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||563.50||| 72080|EAP|0320|XR SPINE THORACOLUMBAR 2|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||5.16||| 72080|EAP|0320|XR SPINE THORACOLUMBAR 2|Managed Medicaid|MEDICAID AMERIGROUP|||||5.16||| 72080|EAP|0320|XR SPINE THORACOLUMBAR 2|Humana Medicare Advantage|HUMANA MA|5.16||||5.16||| 72081|EAP|0320|SCOLIOSIS SERIES|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||5.16||| 72081|EAP|0320|SCOLIOSIS SERIES|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||5.16||| 72081|EAP|0320|SCOLIOSIS SERIES|Managed Medicaid|MEDICAID SUPERIOR|||||5.16||| 72081|EAP|0320|SCOLIOSIS SERIES|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||5.16||| 72081|EAP|0320|SCOLIOSIS SERIES|Managed Medicaid|MEDICAID AMERIGROUP|||||5.16||| 72081|EAP|0320|SCOLIOSIS SERIES|United Healthcare|UNITED HEALTHCARE OTHER|||||5.16||| 72081|EAP|0320|SCOLIOSIS SERIES|Humana Medicare Advantage|HUMANA MA|||||5.16||| 72082|EAP|0320|SPINE ENTIRE 2 0R 3 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||14.00||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|Aetna|AETNA PPO|||||515.75||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||515.75||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|||||515.75||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||515.75||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||515.75||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|Cigna|CIGNA|||||515.75||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|Humana Medicare Advantage|HUMANA MA|515.75||||515.75||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|Blue Cross PPO Specialty|BCBSTX OTHER|||||515.75||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||515.75||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||515.75||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|515.75||||515.75||| 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|United Healthcare|UNITED HEALTHCARE|||||515.75||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|United Healthcare|TML GROUP BENEFITS|||||515.75||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|PHCS|HUMANA INSURANCE|||||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|NON CONTRACTED|COMMERCIAL OTHER 1|||||515.75||| 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|Aenta Medicare Advantage|AETNA MEDICARE MA|||||515.75||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||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|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||515.75||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|Medicaid|MEDICAID|||||515.75||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|Managed Medicare|HEALTHSPRING MA|||||515.75||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||515.75||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||515.75||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||515.75||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||515.75||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||515.75||| 72100|EAP|0320|SPINE LUMBAR 2 OR 3 VIEWS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||515.75||| 72110|EAP|0320|XR SPINE LUMBAR MIN/4 VIE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1,617.50||| 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|United Healthcare|UNITED HEALTHCARE|||||1,617.50||| 72110|EAP|0320|XR SPINE LUMBAR MIN/4 VIE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,617.50||| 72110|EAP|0320|XR SPINE LUMBAR MIN/4 VIE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1,617.50||| 72110|EAP|0320|XR SPINE LUMBAR MIN/4 VIE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||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 AP,LAT,FL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||697.25||| 72110|EAP|0320|XR SPINE LUMBAR AP,LAT,FL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||697.25||| 72110|EAP|0320|XR SPINE LUMBAR MIN/4 VIE|Humana Medicare Advantage|HUMANA MA|||||1,617.50||| 72110|EAP|0320|XR SPINE LUMBAR MIN/4 VIE|Managed Medicaid|MEDICAID SUPERIOR|||||1,617.50||| 72110|EAP|0320|XR SPINE LUMBAR AP,LAT,FL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||697.25||| 72110|EAP|0320|XR SPINE LUMBAR AP,LAT,FL|Blue Cross PPO Specialty|BCBSTX PPO|||||697.25||| 72110|EAP|0320|XR SPINE LUMBAR MIN/4 VIE|Blue Cross HMO Specialty|BCBSTX HMO|||||1,617.50||| 72114|EAP|0320|XR L-SPINE COMP W/FLEX/EX|Blue Cross PPO Specialty|BCBSTX PPO|||||1,663.25||| 72125|EAP|0350|SPINE-CERVICAL W/O CONT|Medicaid|MEDICAID HMO|||||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|Medicaid|MEDICAID|||||3,627.75||| 72125|EAP|0350|SPINE-CERVICAL W/O CONT|Rusk State Hospital|RUSK STATE HOSP|||||3,627.75||| 72125|EAP|0350|SPINE-CERVICAL W/O CONT|NON CONTRACTED|COMMERCIAL OTHER 1|||||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|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 Medicare|MEDICARE ADVANTAGE OTHER MA|||||3,627.75||| 72125|EAP|0350|SPINE-CERVICAL W/O CONT|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||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|United Healthcare|UNITED HEALTHCARE|||||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 Healthcare|UMR UNITED MEDICAL RESOURCES|||||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|Tricare|TRICARE EAST REGION|||||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|Aenta Medicare Advantage|AETNA MEDICARE MA|||||3,627.75||| 72125|EAP|0350|SPINE-CERVICAL W/O CONT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||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|Aetna|AETNA PPO|||||3,627.75||| 72125|EAP|0350|SPINE-CERVICAL W/O CONT|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||3,627.75||| 72125|EAP|0350|SPINE-CERVICAL W/O CONT|Blue Cross HMO Specialty|BCBSTX HMO|||||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|Workers Compensation|WORKERS COMPENSATION OTHER|||||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|Cigna|CIGNA|||||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|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||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|Blue Cross PPO Specialty|BCBSTX OTHER|||||3,627.75||| 72125|EAP|0350|SPINE-CERVICAL W/O CONT|Blue Cross PPO Specialty|BCBSTX PPO|||||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 PPO Specialty|BCBSTX PPO|||||3,627.75||| 72128|EAP|0350|SPINE-THORACIC W/O CONT|Cigna|CIGNA|||||3,627.75||| 72128|EAP|0350|SPINE-THORACIC W/O CONT|Aenta Medicare Advantage|AETNA MEDICARE MA|||||3,627.75||| 72128|EAP|0350|SPINE-THORACIC W/O CONT|Blue Cross HMO Specialty|BCBSTX HMO|||||3,627.75||| 72128|EAP|0350|SPINE-THORACIC W/O CONT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||3,627.75||| 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|Veterans Affairs|VETERANS ADMINISTRATION|||||3,627.75||| 72128|EAP|0350|SPINE-THORACIC W/O CONT|Managed Medicaid|MEDICAID AMERIGROUP|||||3,627.75||| 72128|EAP|0350|SPINE-THORACIC W/O CONT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||3,627.75||| 72128|EAP|0350|SPINE-THORACIC W/O CONT|Workers Compensation|WORKERS COMPENSATION OTHER|||||3,627.75||| 72128|EAP|0350|SPINE-THORACIC W/O CONT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||3,627.75||| 72128|EAP|0350|SPINE-THORACIC W/O CONT|NON CONTRACTED|COMMERCIAL OTHER 1|||||3,627.75||| 72128|EAP|0350|SPINE-THORACIC W/O CONT|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||3,627.75||| 72128|EAP|0350|SPINE-THORACIC W/O CONT|United Medicare Advantage|UHC MEDICARE GOLD MA|||||3,627.75||| 72128|EAP|0350|SPINE-THORACIC W/O CONT|Tricare|TRICARE EAST REGION|||||3,627.75||| 72128|EAP|0350|SPINE-THORACIC W/O CONT|Medicare|MEDICARE ACUTE|3,627.75||||3,627.75||| 72131|EAP|0350|SPINE-LUMBAR W/O CONT|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||3,627.75||| 72131|EAP|0350|SPINE-LUMBAR W/O CONT|NON CONTRACTED|COMMERCIAL OTHER 1|||||3,627.75||| 72131|EAP|0350|SPINE-LUMBAR W/O CONT|Medicare|MEDICARE ACUTE|3,627.75||||3,627.75||| 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 UNITED HEALTHCARE|||||3,627.75||| 72131|EAP|0350|SPINE-LUMBAR W/O CONT|United Medicare Advantage|UHC MEDICARE GOLD MA|||||3,627.75||| 72131|EAP|0350|SPINE-LUMBAR W/O CONT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||3,627.75||| 72131|EAP|0350|SPINE-LUMBAR W/O CONT|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||3,627.75||| 72131|EAP|0350|SPINE-LUMBAR W/O CONT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3,627.75||||3,627.75||| 72131|EAP|0350|SPINE-LUMBAR W/O CONT|Veterans Affairs|VETERANS ADMINISTRATION|||||3,627.75||| 72131|EAP|0350|SPINE-LUMBAR W/O CONT|Workers Compensation|WORKERS COMPENSATION OTHER|||||3,627.75||| 72131|EAP|0350|SPINE-LUMBAR W/O CONT|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||3,627.75||| 72131|EAP|0350|SPINE-LUMBAR W/O CONT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3,627.75||| 72131|EAP|0350|SPINE-LUMBAR W/O CONT|Blue Cross HMO Specialty|BCBSTX HMO|||||3,627.75||| 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|||||3,627.75||| 72131|EAP|0350|SPINE-LUMBAR W/O CONT|Blue Cross PPO Specialty|BCBSTX OTHER|||||3,627.75||| 72131|EAP|0350|SPINE-LUMBAR W/O CONT|Cigna|CIGNA|||||3,627.75||| 72131|EAP|0350|SPINE-LUMBAR W/O CONT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||3,627.75||| 72131|EAP|0350|SPINE-LUMBAR W/O CONT|Humana Medicare Advantage|HUMANA MA|3,627.75||||3,627.75||| 72132|EAP|0350|SPINE-LUMBAR W/CONTRAST|Workers Compensation|WORKERS COMPENSATION OTHER|||||33.50||| 72132|EAP|0350|SPINE-LUMBAR W/CONTRAST|Medicare|MEDICARE ACUTE|||||33.50||| 72132|EAP|0350|SPINE-LUMBAR W/CONTRAST|Medicaid|MEDICAID|||||33.50||| 72141|EAP|0612|MRI CERVICAL SPINE W/O CO|Managed Medicaid|MEDICAID AMERIGROUP|||||58.50||| 72141|EAP|0612|MRI CERVICAL SPINE W/O CO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||58.50||| 72141|EAP|0612|MRI CERVICAL SPINE W/O CO|NON CONTRACTED|COMMERCIAL OTHER 1|||||58.50||| 72141|EAP|0612|MRI CERVICAL SPINE W/O CO|Medicare|MEDICARE ACUTE|58.50||||58.50||| 72141|EAP|0612|MRI CERVICAL SPINE W/O CO|Medicaid|MEDICAID|||||58.50||| 72141|EAP|0612|MRI CERVICAL SPINE W/O CO|Blue Cross PPO Specialty|BCBSTX PPO|||||58.50||| 72141|EAP|0612|MRI CERVICAL SPINE W/O CO|Cigna|CIGNA|||||58.50||| 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|||||58.50||| 72141|EAP|0612|MRI CERVICAL SPINE W/O CO|Blue Cross HMO Specialty|BCBSTX HMO|||||58.50||| 72141|EAP|0612|MRI CERVICAL SPINE W/O CO|Aetna|AETNA OTHER|||||58.50||| 72141|EAP|0612|MRI CERVICAL SPINE W/O CO|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||58.50||| 72141|EAP|0612|MRI CERVICAL SPINE W/O CO|Aenta Medicare Advantage|AETNA MEDICARE MA|||||58.50||| 72141|EAP|0612|MRI CERVICAL SPINE W/O CO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||58.50||| 72141|EAP|0612|MRI CERVICAL SPINE W/O CO|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||58.50||| 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|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||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|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||58.50||| 72141|EAP|0612|MRI CERVICAL SPINE W/O CO|United Healthcare|UNITED HEALTHCARE OTHER|||||58.50||| 72141|EAP|0612|MRI CERVICAL SPINE W/O CO|Workers Compensation|WORKERS COMPENSATION OTHER|||||58.50||| 72141|EAP|0612|MRI CERVICAL SPINE W/O CO|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||58.50||| 72141|EAP|0612|MRI CERVICAL SPINE W/O CO|United Healthcare|UNITED HEALTHCARE|||||58.50||| 72146|EAP|0612|MRI_THORACIC SPINE W/O CO|United Medicare Advantage|UHC MEDICARE GOLD MA|||||58.50||| 72146|EAP|0612|MRI_THORACIC SPINE W/O CO|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||58.50||| 72146|EAP|0612|MRI_THORACIC SPINE W/O CO|Blue Cross HMO Specialty|BCBSTX HMO|||||58.50||| 72146|EAP|0612|MRI_THORACIC SPINE W/O CO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||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|Aetna|AETNA OTHER|||||58.50||| 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|Cigna|CIGNA|||||58.50||| 72146|EAP|0612|MRI_THORACIC SPINE W/O CO|Humana Medicare Advantage|HUMANA MA|||||58.50||| 72146|EAP|0612|MRI_THORACIC SPINE W/O CO|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||58.50||| 72146|EAP|0612|MRI_THORACIC SPINE W/O CO|Managed Medicaid|MEDICAID AMERIGROUP|||||58.50||| 72146|EAP|0612|MRI_THORACIC SPINE W/O CO|Managed Medicaid|MEDICAID SUPERIOR|||||58.50||| 72146|EAP|0612|MRI_THORACIC SPINE W/O CO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||58.50||| 72146|EAP|0612|MRI_THORACIC SPINE W/O CO|Medicare|MEDICARE ACUTE|58.50||||58.50||| 72146|EAP|0612|MRI_THORACIC SPINE W/O CO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||58.50||| 72146|EAP|0612|MRI_THORACIC SPINE W/O CO|NON CONTRACTED|COMMERCIAL OTHER 1|||||58.50||| 72146|EAP|0612|MRI_THORACIC SPINE W/O CO|PHCS|HUMANA INSURANCE|||||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 Medicare|MEDICARE ADVANTAGE OTHER MA|||||58.50||| 72148|EAP|0612|MRI LUMBAR SPINE W/O CONT|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||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|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||58.50||| 72148|EAP|0612|MRI LUMBAR SPINE W/O CONT|Managed Medicaid|MEDICAID SUPERIOR|||||58.50||| 72148|EAP|0612|MRI LUMBAR SPINE W/O CONT|Medicare|MEDICARE ACUTE|58.50||||58.50||| 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|||||58.50||| 72148|EAP|0612|MRI LUMBAR SPINE W/O CONT|Medicaid|MEDICAID|||||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 Medicare|HEALTHSPRING MA|||||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|Blue Cross HMO Specialty|BCBSTX HMO|||||58.50||| 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|||||58.50||| 72148|EAP|0612|MRI LUMBAR SPINE W/O CONT|Blue Cross PPO Specialty|BCBSTX OTHER|||||58.50||| 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|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||58.50||| 72148|EAP|0612|MRI LUMBAR SPINE W/O CONT|Aetna|AETNA OTHER|||||58.50||| 72148|EAP|0612|MRI LUMBAR SPINE W/O CONT|United Healthcare|UNITED HEALTHCARE|||||58.50||| 72148|EAP|0612|MRI LUMBAR SPINE W/O CONT|United Healthcare|UNITED HEALTHCARE OTHER|||||58.50||| 72148|EAP|0612|MRI LUMBAR SPINE W/O CONT|United Medicare Advantage|UHC MEDICARE GOLD MA|||||58.50||| 72148|EAP|0612|MRI LUMBAR SPINE W/O CONT|Cigna|CIGNA|||||58.50||| 72148|EAP|0612|MRI LUMBAR SPINE W/O CONT|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||58.50||| 72148|EAP|0612|MRI LUMBAR SPINE W/O CONT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|58.50||||58.50||| 72148|EAP|0612|MRI LUMBAR SPINE W/O CONT|Workers Compensation|WORKERS COMPENSATION OTHER|||||58.50||| 72156|EAP|0612|MRI C SPINE W/WO CONTRAST|Humana Medicare Advantage|HUMANA MA|||||7,914.25||| 72156|EAP|0612|MRI C SPINE W/WO CONTRAST|Medicare|MEDICARE ACUTE|||||7,914.25||| 72156|EAP|0612|MRI C SPINE W/WO CONTRAST|Managed Medicare|HEALTHSPRING MA|7,914.25||||||| 72156|EAP|0612|MRI C SPINE W/WO CONTRAST|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||7,914.25||| 72157|EAP|0612|MRI T SPINE W/WO CONTRAST|Medicare|MEDICARE ACUTE|||||7,914.25||| 72158|EAP|0612|MRI L SPINE W/WO CONTRAST|United Medicare Advantage|UHC MEDICARE GOLD MA|||||7,914.25||| 72158|EAP|0612|MRI L SPINE W/WO CONTRAST|Aenta Medicare Advantage|AETNA MEDICARE MA|||||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 Healthcare|UNITED HEALTHCARE|||||7,914.25||| 72158|EAP|0612|MRI L SPINE W/WO CONTRAST|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||7,914.25||| 72158|EAP|0612|MRI L SPINE W/WO CONTRAST|Blue Cross HMO Specialty|BCBSTX HMO|||||7,914.25||| 72158|EAP|0612|MRI L SPINE W/WO CONTRAST|Medicare|MEDICARE ACUTE|||||7,914.25||| 72170|EAP|0320|XR PELVIS 1 OR 2 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|||||5.16||| 72170|EAP|0320|XR PELVIS 1 OR 2 VIEWS|Medicare|MEDICARE ACUTE|||||5.16||| 72170|EAP|0320|XR PELVIS 1 OR 2 VIEWS|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||5.16||| 72170|EAP|0320|XR PELVIS 1 OR 2 VIEWS|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||5.16||| 72170|EAP|0320|XR PELVIS 1 OR 2 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||5.16||| 72170|EAP|0320|XR PELVIS 1 OR 2 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||5.16||| 72170|EAP|0320|XR PELVIS 1 OR 2 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||5.16||| 72170|EAP|0320|XR PELVIS 1 OR 2 VIEWS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||5.16||| 72170|EAP|0320|XR PELVIS 1 OR 2 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||5.16||| 72192|EAP|0350|CT PELVIS W/O CONTRAST|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3,627.75||||3,627.75||| 72192|EAP|0350|CT PELVIS W/O CONTRAST|Blue Cross HMO Specialty|BCBSTX HMO|||||3,627.75||| 72192|EAP|0350|CT PELVIS W/O CONTRAST|Blue Cross PPO Specialty|BCBSTX PPO|3,627.75||||||| 72192|EAP|0350|CT PELVIS W/O CONTRAST|Humana Medicare Advantage|HUMANA MA|||||3,627.75||| 72192|EAP|0350|CT PELVIS W/O CONTRAST|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||3,627.75||| 72192|EAP|0350|CT PELVIS W/O CONTRAST|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||3,627.75||| 72192|EAP|0350|CT PELVIS W/O CONTRAST|Managed Medicaid|MEDICAID SUPERIOR|||||3,627.75||| 72192|EAP|0350|CT PELVIS W/O CONTRAST|Medicaid|MEDICAID|3,627.75||||||| 72192|EAP|0350|CT PELVIS W/O CONTRAST|Medicare|MEDICARE ACUTE|3,627.75||||3,627.75||| 72193|EAP|0350|CT PELVIS W/CONTRAST|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||4,738.75||| 72193|EAP|0350|CT PELVIS W/CONTRAST|NON CONTRACTED|COMMERCIAL OTHER 1|||||4,738.75||| 72193|EAP|0350|CT PELVIS W/CONTRAST|Medicare|MEDICARE ACUTE|||||4,738.75||| 72193|EAP|0350|CT PELVIS W/CONTRAST|Humana Medicare Advantage|HUMANA MA|4,738.75||||||| 72193|EAP|0350|CT PELVIS W/CONTRAST|Blue Cross PPO Specialty|BCBSTX PPO|||||4,738.75||| 72193|EAP|0350|CT PELVIS W/CONTRAST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4,738.75||||||| 72193|EAP|0350|CT PELVIS W/CONTRAST|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||4,738.75||| 72194|EAP|0352|CT PELVIS W/W/O CONTRAST|Managed Medicaid|MEDICAID UNITED HEALTHCARE|53.74||||||| 72195|EAP|0610|MRI PELVIS W/O CONTRAST|Humana Medicare Advantage|HUMANA MA|||||58.50||| 72195|EAP|0610|MRI PELVIS W/O CONTRAST|Blue Cross PPO Specialty|BCBSTX OTHER|||||58.50||| 72195|EAP|0610|MRI PELVIS W/O CONTRAST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||58.50||| 72195|EAP|0610|MRI PELVIS W/O CONTRAST|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||58.50||| 72195|EAP|0610|MRI PELVIS W/O CONTRAST|United Medicare Advantage|UHC MEDICARE GOLD MA|||||58.50||| 72195|EAP|0610|MRI PELVIS W/O CONTRAST|Medicare|MEDICARE ACUTE|||||58.50||| 72197|EAP|0612|MRI PELVIS W/WO CONTRAST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7,914.25||||||| 72200|EAP|0320|SACROILIAC JOINTS|Managed Medicaid|MEDICAID SUPERIOR|||||515.75||| 72200|EAP|0320|SACROILIAC JOINTS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||515.75||| 72200|EAP|0320|SACROILIAC JOINTS|Blue Cross PPO Specialty|BCBSTX PPO|||||515.75||| 72220|EAP|0320|SACRUM 2 VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||515.75||| 72220|EAP|0320|SACRUM 2 VIEWS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||515.75||| 72220|EAP|0320|SACRUM 2 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||515.75||| 72220|EAP|0320|SACRUM 2 VIEWS|United Healthcare|TML GROUP BENEFITS|||||515.75||| 72220|EAP|0320|SACRUM 2 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|||||515.75||| 72220|EAP|0320|SACRUM 2 VIEWS|Medicaid|MEDICAID|||||515.75||| 72220|EAP|0320|SACRUM 2 VIEWS|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||515.75||| 72220|EAP|0320|SACRUM 2 VIEWS|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||515.75||| 72220|EAP|0320|SACRUM 2 VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|||||515.75||| 72220|EAP|0320|SACRUM 2 VIEWS|Medicare|MEDICARE ACUTE|||||515.75||| 72220|EAP|0320|SACRUM 2 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||515.75||| 72220|EAP|0320|SACRUM 2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||515.75||| 72220|EAP|0320|SACRUM 2 VIEWS|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||515.75||| 73000|EAP|0320|CLAVICLE LT. COMPLETE|Medicaid|MEDICAID|||||515.75||| 73000|EAP|0320|CLAVICLE LT. COMPLETE|Managed Medicaid|MEDICAID AMERIGROUP|||||515.75||| 73000|EAP|0320|CLAVICLE RT.COMPLETE|Managed Medicaid|MEDICAID AMERIGROUP|||||515.75||| 73000|EAP|0320|CLAVICLE RT.COMPLETE|Managed Medicaid|MEDICAID SUPERIOR|||||515.75||| 73000|EAP|0320|CLAVICLE RT.COMPLETE|Medicare|MEDICARE ACUTE|||||515.75||| 73000|EAP|0320|CLAVICLE LT. COMPLETE|United Healthcare|UNITED HEALTHCARE|||||515.75||| 73000|EAP|0320|CLAVICLE RT.COMPLETE|United Healthcare|UNITED HEALTHCARE|||||515.75||| 73000|EAP|0320|CLAVICLE LT. COMPLETE|Blue Cross PPO Specialty|BCBSTX PPO|||||515.75||| 73000|EAP|0320|CLAVICLE LT. COMPLETE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||515.75||| 73000|EAP|0320|CLAVICLE RT.COMPLETE|Blue Cross PPO Specialty|BCBSTX PPO|||||515.75||| 73000|EAP|0320|CLAVICLE RT.COMPLETE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||515.75||| 73010|EAP|0320|SCAPULA LT.2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||515.75||| 73020|EAP|0320|SHOULDER RT. 1 VIEW|Blue Cross HMO Specialty|BCBSTX HMO|||||452.25||| 73020|EAP|0320|SHOULDER RT. 1 VIEW|United Healthcare|UNITED HEALTHCARE OTHER|||||452.25||| 73020|EAP|0320|SHOULDER LT.1 VIEW|Blue Cross PPO Specialty|BCBSTX OTHER|||||452.25||| 73020|EAP|0320|SHOULDER RT. 1 VIEW|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||452.25||| 73030|EAP|0320|SHOULDER RT. 2 VIEWS|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||515.75||| 73030|EAP|0320|SHOULDER 3V RIGHT|NON CONTRACTED|COMMERCIAL OTHER 1|||||515.75||| 73030|EAP|0320|SHOULDER 3V RIGHT|Medicaid|MEDICAID HMO|||||515.75||| 73030|EAP|0320|SHOULDER 3V LEFT|Medicaid|MEDICAID|||||515.75||| 73030|EAP|0320|SHOULDER 3V LEFT|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||515.75||| 73030|EAP|0320|SHOULDER 3V RIGHT|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||515.75||| 73030|EAP|0320|SHOULDER 3V RIGHT|Medicare|MEDICARE ACUTE|515.75||||515.75||| 73030|EAP|0320|SHOULDER RT. 2 VIEWS|Medicare|MEDICARE ACUTE|515.75||||515.75||| 73030|EAP|0320|SHOULDER LT.2 VIEWS|Rusk State Hospital|RUSK STATE HOSP|||||515.75||| 73030|EAP|0320|SHOULDER RT. 2 VIEWS|Rusk State Hospital|RUSK STATE HOSP|||||515.75||| 73030|EAP|0320|SHOULDER 3V LEFT|NON CONTRACTED|COMMERCIAL OTHER 1|||||515.75||| 73030|EAP|0320|SHOULDER 3V RIGHT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||515.75||| 73030|EAP|0320|SHOULDER 3V LEFT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|515.75||||515.75||| 73030|EAP|0320|SHOULDER RT. 2 VIEWS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||515.75||| 73030|EAP|0320|SHOULDER RT. 2 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|515.75||||515.75||| 73030|EAP|0320|SHOULDER 3V RIGHT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|515.75||||515.75||| 73030|EAP|0320|SHOULDER RT. 2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||515.75||| 73030|EAP|0320|SHOULDER 3V LEFT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||515.75||| 73030|EAP|0320|SHOULDER 3V RIGHT|Managed Medicaid|MEDICAID AMERIGROUP|||||515.75||| 73030|EAP|0320|SHOULDER LT.2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||515.75||| 73030|EAP|0320|SHOULDER 3V RIGHT|Managed Medicaid|MEDICAID SUPERIOR|||||515.75||| 73030|EAP|0320|SHOULDER 3V RIGHT|Workers Compensation|WORKERS COMPENSATION OTHER|||||515.75||| 73030|EAP|0320|SHOULDER LT.2 VIEWS|Workers Compensation|WORKERS COMPENSATION OTHER|||||515.75||| 73030|EAP|0320|SHOULDER 3V RIGHT|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||515.75||| 73030|EAP|0320|SHOULDER 3V LEFT|Workers Compensation|WORKERS COMPENSATION OTHER|||||515.75||| 73030|EAP|0320|SHOULDER 3V RIGHT|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||515.75||| 73030|EAP|0320|SHOULDER 3V RIGHT|United Healthcare|UNITED HEALTHCARE|||||515.75||| 73030|EAP|0320|SHOULDER 3V LEFT|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||515.75||| 73030|EAP|0320|SHOULDER 3V LEFT|Managed Medicaid|MEDICAID SUPERIOR|||||515.75||| 73030|EAP|0320|SHOULDER RT. 2 VIEWS|United Healthcare|UNITED HEALTHCARE|||||515.75||| 73030|EAP|0320|SHOULDER 3V LEFT|United Healthcare|UNITED HEALTHCARE OTHER|||||515.75||| 73030|EAP|0320|SHOULDER 3V LEFT|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||515.75||| 73030|EAP|0320|SHOULDER 3V RIGHT|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||515.75||| 73030|EAP|0320|SHOULDER RT. 2 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|515.75||||515.75||| 73030|EAP|0320|SHOULDER 3V LEFT|United Healthcare|TML GROUP BENEFITS|||||515.75||| 73030|EAP|0320|SHOULDER 3V LEFT|Veterans Affairs|VETERANS ADMINISTRATION|||||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|Managed Medicaid|MEDICAID AMERIGROUP|||||515.75||| 73030|EAP|0320|SHOULDER 3V LEFT|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||515.75||| 73030|EAP|0320|SHOULDER 3V LEFT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||515.75||| 73030|EAP|0320|SHOULDER 3V RIGHT|United Healthcare|UNITED HEALTHCARE OTHER|||||515.75||| 73030|EAP|0320|SHOULDER RT. 2 VIEWS|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||515.75||| 73030|EAP|0320|SHOULDER 3V RIGHT|United Medicare Advantage|UHC MEDICARE GOLD MA|515.75||||515.75||| 73030|EAP|0320|SHOULDER 3V LEFT|Medicare|MEDICARE ACUTE|515.75||||515.75||| 73030|EAP|0320|SHOULDER 3V LEFT|United Medicare Advantage|UHC MEDICARE GOLD MA|515.75||||515.75||| 73030|EAP|0320|SHOULDER 3V RIGHT|Blue Cross PPO Specialty|BCBSTX PPO|||||515.75||| 73030|EAP|0320|SHOULDER LT.2 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||515.75||| 73030|EAP|0320|SHOULDER 3V LEFT|Blue Cross PPO Specialty|BCBSTX PPO|||||515.75||| 73030|EAP|0320|SHOULDER RT. 2 VIEWS|Humana Medicare Advantage|HUMANA MA|515.75||||515.75||| 73030|EAP|0320|SHOULDER 3V RIGHT|Veterans Affairs|VETERANS ADMINISTRATION|||||515.75||| 73030|EAP|0320|SHOULDER 3V LEFT|Blue Cross PPO Specialty|BCBSTX OTHER|||||515.75||| 73030|EAP|0320|SHOULDER 3V RIGHT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||515.75||| 73030|EAP|0320|SHOULDER 3V LEFT|Humana Medicare Advantage|HUMANA MA|515.75||||515.75||| 73030|EAP|0320|SHOULDER LT.2 VIEWS|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||515.75||| 73030|EAP|0320|SHOULDER LT.2 VIEWS|Humana Medicare Advantage|HUMANA MA|515.75||||515.75||| 73030|EAP|0320|SHOULDER 3V RIGHT|Humana Medicare Advantage|HUMANA MA|515.75||||515.75||| 73030|EAP|0320|SHOULDER 3V LEFT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||515.75||| 73030|EAP|0320|SHOULDER 3V RIGHT|Aetna|AETNA OTHER|||||515.75||| 73030|EAP|0320|SHOULDER 3V LEFT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|515.75||||515.75||| 73030|EAP|0320|SHOULDER 3V LEFT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||515.75||| 73030|EAP|0320|SHOULDER 3V RIGHT|Blue Cross HMO Specialty|BCBSTX HMO|||||515.75||| 73030|EAP|0320|SHOULDER 3V RIGHT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||515.75||| 73030|EAP|0320|SHOULDER 3V LEFT|Aenta Medicare Advantage|AETNA MEDICARE MA|515.75||||515.75||| 73030|EAP|0320|SHOULDER 3V RIGHT|Aenta Medicare Advantage|AETNA MEDICARE MA|515.75||||515.75||| 73030|EAP|0320|SHOULDER 3V RIGHT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|515.75||||515.75||| 73040|EAP|0322|ARTHROGRAM RT.SHOULDER|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||914.25||| 73040|EAP|0322|ARTHROGRAM RT.SHOULDER|Blue Cross HMO Specialty|BCBSTX HMO|||||914.25||| 73040|EAP|0322|ARTHROGRAM LT.SHOULDER|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||914.25||| 73040|EAP|0322|ARTHROGRAM RT.SHOULDER|Humana Medicare Advantage|HUMANA MA|||||914.25||| 73040|EAP|0322|ARTHROGRAM LT.SHOULDER|Medicare|MEDICARE ACUTE|||||914.25||| 73050|EAP|0320|ACROMIOCLAVICULAR JOINTS|Medicare|MEDICARE ACUTE|||||5.71||| 73060|EAP|0320|HUMERUS RT.2 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||515.75||| 73060|EAP|0320|HUMERUS RT.2 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||515.75||| 73060|EAP|0320|HUMERUS LT.2 VIEWS|Cigna|CIGNA|||||515.75||| 73060|EAP|0320|HUMERUS RT.2 VIEWS|Humana Medicare Advantage|HUMANA MA|515.75||||515.75||| 73060|EAP|0320|HUMERUS RT.2 VIEWS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||515.75||| 73060|EAP|0320|HUMERUS LT.2 VIEWS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||515.75||| 73060|EAP|0320|HUMERUS LT.2 VIEWS|Humana Medicare Advantage|HUMANA MA|515.75||||515.75||| 73060|EAP|0320|HUMERUS RT.2 VIEWS|Aenta Medicare Advantage|AETNA MEDICARE MA|515.75||||515.75||| 73060|EAP|0320|HUMERUS RT.2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||515.75||| 73060|EAP|0320|HUMERUS RT.2 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||515.75||| 73060|EAP|0320|HUMERUS LT.2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||515.75||| 73060|EAP|0320|HUMERUS RT.2 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||515.75||| 73060|EAP|0320|HUMERUS LT.2 VIEWS|Medicare|MEDICARE ACUTE|||||515.75||| 73060|EAP|0320|HUMERUS LT.2 VIEWS|Rusk State Hospital|RUSK STATE HOSP|||||515.75||| 73060|EAP|0320|HUMERUS RT.2 VIEWS|Medicare|MEDICARE ACUTE|||||515.75||| 73060|EAP|0320|XR HUMERUS LT 1 VIEW|Medicare|MEDICARE ACUTE|||||5.16||| 73060|EAP|0320|HUMERUS LT.2 VIEWS|Medicare|MEDICARE PART B ONLY IP|||||515.75||| 73070|EAP|0320|ELBOW RT.2 VIEWS|Medicare|MEDICARE ACUTE|515.75||||515.75||| 73070|EAP|0320|ELBOW LT.2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||515.75||| 73070|EAP|0320|ELBOW RT.2 VIEWS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||515.75||| 73070|EAP|0320|ELBOW RT.2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||515.75||| 73070|EAP|0320|ELBOW LT.2 VIEWS|United Healthcare|UNITED HEALTHCARE|||||515.75||| 73070|EAP|0320|ELBOW RT.2 VIEWS|Humana Medicare Advantage|HUMANA MA|||||515.75||| 73080|EAP|0320|ELBOW RT.3 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||5.71||| 73080|EAP|0320|XR ELBOW LT 3 VIEWS OR MO|United Medicare Advantage|UHC MEDICARE GOLD MA|||||5.16||| 73080|EAP|0320|XR ELBOW LT 3 VIEWS OR MO|Blue Cross HMO Specialty|BCBSTX HMO|||||5.16||| 73080|EAP|0320|XR ELBOW LT 3 VIEWS OR MO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||5.16||| 73080|EAP|0320|ELBOW RT.3 VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|||||5.71||| 73080|EAP|0320|ELBOW RT.3 VIEWS|Humana Medicare Advantage|HUMANA MA|||||5.71||| 73080|EAP|0320|ELBOW RT.3 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||5.71||| 73080|EAP|0320|XR ELBOW LT 3 VIEWS OR MO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||5.16||| 73080|EAP|0320|ELBOW RT.3 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||5.71||| 73080|EAP|0320|XR ELBOW LT 3 VIEWS OR MO|Managed Medicaid|MEDICAID AMERIGROUP|||||5.16||| 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|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||5.16||| 73080|EAP|0320|ELBOW RT.3 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||5.71||| 73080|EAP|0320|ELBOW RT.3 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||5.71||| 73080|EAP|0320|ELBOW RT.3 VIEWS|Medicaid|MEDICAID TEXAS CHILDRENS|||||5.71||| 73080|EAP|0320|ELBOW RT.3 VIEWS|Medicare|MEDICARE ACUTE|5.71||||5.71||| 73080|EAP|0320|XR ELBOW LT 3 VIEWS OR MO|Medicaid|MEDICAID PCCM|||||5.16||| 73080|EAP|0320|XR ELBOW LT 3 VIEWS OR MO|Medicare|MEDICARE ACUTE|5.16||||5.16||| 73080|EAP|0320|XR ELBOW LT 3 VIEWS OR MO|Blue Cross PPO Specialty|BCBSTX PPO|||||5.16||| 73080|EAP|0320|ELBOW RT.3 VIEWS|Medicaid|MEDICAID|||||5.71||| 73080|EAP|0320|ELBOW RT.3 VIEWS|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||5.71||| 73080|EAP|0320|XR ELBOW LT 3 VIEWS OR MO|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||5.16||| 73090|EAP|0320|FOREARM LT.2 VIEWS|Medicaid|MEDICAID|||||515.75||| 73090|EAP|0320|FOREARM RT.2 VIEWS|Medicaid|MEDICAID|||||515.75||| 73090|EAP|0320|FOREARM RT.2 VIEWS|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||515.75||| 73090|EAP|0320|FOREARM RT.2 VIEWS|Medicare|MEDICARE ACUTE|515.75||||515.75||| 73090|EAP|0320|FOREARM RT.2 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||515.75||| 73090|EAP|0320|FOREARM RT.2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||515.75||| 73090|EAP|0320|FOREARM LT.2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||515.75||| 73090|EAP|0320|FOREARM RT.2 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||515.75||| 73090|EAP|0320|FOREARM LT.2 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||515.75||| 73090|EAP|0320|FOREARM RT.2 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|515.75||||515.75||| 73090|EAP|0320|FOREARM LT.2 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|515.75||||515.75||| 73090|EAP|0320|FOREARM RT.2 VIEWS|Cigna|CIGNA|||||515.75||| 73090|EAP|0320|FOREARM RT.2 VIEWS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||515.75||| 73090|EAP|0320|FOREARM LT.2 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||515.75||| 73090|EAP|0320|FOREARM LT.2 VIEWS|Medicare|MEDICARE ACUTE|515.75||||515.75||| 73090|EAP|0320|FOREARM LT.2 VIEWS|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||515.75||| 73090|EAP|0320|FOREARM LT.2 VIEWS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||515.75||| 73090|EAP|0320|FOREARM RT.2 VIEWS|Humana Medicare Advantage|HUMANA MA|||||515.75||| 73090|EAP|0320|FOREARM LT.2 VIEWS|Humana Medicare Advantage|HUMANA MA|||||515.75||| 73090|EAP|0320|FOREARM RT.2 VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|||||515.75||| 73090|EAP|0320|FOREARM RT.2 VIEWS|Aetna|AETNA OTHER|||||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|||||515.75||| 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|NON CONTRACTED|COMMERCIAL OTHER 1|||||515.75||| 73092|EAP|0320|EXTREMITY RT.UPPER INFANT|Managed Medicaid|MEDICAID SUPERIOR|||||5.71||| 73100|EAP|0320|WRIST,LT.2 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||515.75||| 73100|EAP|0320|WRIST,LT.2 VIEWS|Humana Medicare Advantage|HUMANA MA|515.75||||515.75||| 73100|EAP|0320|WRIST,LT.2 VIEWS|Medicare|MEDICARE ACUTE|515.75||||515.75||| 73100|EAP|0320|WRIST,LT.2 VIEWS|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||515.75||| 73100|EAP|0320|WRIST,LT.2 VIEWS|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||515.75||| 73100|EAP|0320|WRIST,LT.2 VIEWS|Medicaid|MEDICAID|||||515.75||| 73100|EAP|0320|WRIST RT.2 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|515.75||||||| 73100|EAP|0320|WRIST RT.2 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||515.75||| 73110|EAP|0320|WRIST,LT.COMP 3 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||5.71||| 73110|EAP|0320|WRIST, RT. COMPLETE 3 VIE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||5.71||| 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 UNITED HEALTHCARE|||||5.71||| 73110|EAP|0320|WRIST,LT.COMP 3 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||5.71||| 73110|EAP|0320|WRIST, RT. COMPLETE 3 VIE|Managed Medicaid|MEDICAID AMERIGROUP|||||5.71||| 73110|EAP|0320|WRIST, RT. COMPLETE 3 VIE|PHCS|HUMANA INSURANCE|||||5.71||| 73110|EAP|0320|WRIST,LT.COMP 3 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|5.71||||5.71||| 73110|EAP|0320|WRIST,LT.COMP 3 VIEWS|Medicaid|MEDICAID HMO|||||5.71||| 73110|EAP|0320|WRIST, RT. COMPLETE 3 VIE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||5.71||| 73110|EAP|0320|WRIST,LT.COMP 3 VIEWS|Medicare|MEDICARE ACUTE|5.71||||5.71||| 73110|EAP|0320|WRIST, RT. COMPLETE 3 VIE|Tricare|TRICARE EAST REGION|||||5.71||| 73110|EAP|0320|WRIST,LT.COMP 3 VIEWS|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||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|UHC DUAL COMPLETE HMO SNP MA|||||5.71||| 73110|EAP|0320|WRIST, RT. COMPLETE 3 VIE|Medicare|MEDICARE ACUTE|5.71||||5.71||| 73110|EAP|0320|WRIST, RT. COMPLETE 3 VIE|United Healthcare|UNITED HEALTHCARE|||||5.71||| 73110|EAP|0320|WRIST,LT.COMP 3 VIEWS|Workers Compensation|WORKERS COMPENSATION OTHER|||||5.71||| 73110|EAP|0320|WRIST,LT.COMP 3 VIEWS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||5.71||| 73110|EAP|0320|WRIST, RT. COMPLETE 3 VIE|Veterans Affairs|VETERANS ADMINISTRATION|||||5.71||| 73110|EAP|0320|WRIST, RT. COMPLETE 3 VIE|Workers Compensation|WORKERS COMPENSATION OTHER|||||5.71||| 73110|EAP|0320|WRIST, RT. COMPLETE 3 VIE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||5.71||| 73110|EAP|0320|WRIST, RT. COMPLETE 3 VIE|NON CONTRACTED|COMMERCIAL OTHER 1|5.71||||5.71||| 73110|EAP|0320|WRIST,LT.COMP 3 VIEWS|United Healthcare|UNITED HEALTHCARE OTHER|||||5.71||| 73110|EAP|0320|WRIST,LT.COMP 3 VIEWS|Medicaid|MEDICAID|||||5.71||| 73110|EAP|0320|WRIST,LT.COMP 3 VIEWS|United Healthcare|UNITED HEALTHCARE|||||5.71||| 73110|EAP|0320|WRIST, RT. COMPLETE 3 VIE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||5.71||| 73110|EAP|0320|WRIST, RT. COMPLETE 3 VIE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||5.71||| 73110|EAP|0320|WRIST, RT. COMPLETE 3 VIE|Blue Cross HMO Specialty|BCBSTX HMO|||||5.71||| 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 SUPERIOR|||||5.71||| 73110|EAP|0320|WRIST,LT.COMP 3 VIEWS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||5.71||| 73110|EAP|0320|WRIST,LT.COMP 3 VIEWS|Aenta Medicare Advantage|AETNA MEDICARE MA|||||5.71||| 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|Blue Cross PPO Specialty|BCBSTX PPO|5.71||||5.71||| 73110|EAP|0320|WRIST, RT. COMPLETE 3 VIE|Humana Medicare Advantage|HUMANA MA|5.71||||5.71||| 73110|EAP|0320|WRIST,LT.COMP 3 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||5.71||| 73110|EAP|0320|WRIST, RT. COMPLETE 3 VIE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||5.71||| 73110|EAP|0320|WRIST,LT.COMP 3 VIEWS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||5.71||| 73110|EAP|0320|WRIST,LT.COMP 3 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|5.71||||5.71||| 73110|EAP|0320|WRIST, RT. COMPLETE 3 VIE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||5.71||| 73110|EAP|0320|WRIST,LT.COMP 3 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||5.71||| 73110|EAP|0320|WRIST,LT.COMP 3 VIEWS|Humana Medicare Advantage|HUMANA MA|5.71||||5.71||| 73110|EAP|0320|WRIST,LT.COMP 3 VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|||||5.71||| 73120|EAP|0320|HAND LEFT 2 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||515.75||| 73120|EAP|0320|HAND RIGHT 2 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||515.75||| 73120|EAP|0320|HAND LEFT 2 VIEWS|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||515.75||| 73120|EAP|0320|HAND RIGHT 2 VIEWS|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||515.75||| 73120|EAP|0320|HAND RIGHT 2 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||515.75||| 73120|EAP|0320|HAND RIGHT 2 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||515.75||| 73130|EAP|0320|HAND LT.3 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||5.71||| 73130|EAP|0320|HAND RT.3 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||5.71||| 73130|EAP|0320|HAND LT.3 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||5.71||| 73130|EAP|0320|HAND LT.3 VIEWS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||5.71||| 73130|EAP|0320|HAND RT.3 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||5.71||| 73130|EAP|0320|HAND RT.3 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|5.71||||5.71||| 73130|EAP|0320|HAND LT.3 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||5.71||| 73130|EAP|0320|HAND LT.3 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|5.71||||5.71||| 73130|EAP|0320|HAND RT.3 VIEWS|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||5.71||| 73130|EAP|0320|HAND RT.3 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|||||5.71||| 73130|EAP|0320|HAND RT.3 VIEWS|Rusk State Hospital|RUSK STATE HOSP|||||5.71||| 73130|EAP|0320|HAND RT.3 VIEWS|Medicaid|MEDICAID|5.71||||5.71||| 73130|EAP|0320|HAND RT.3 VIEWS|Medicaid|MEDICAID TEXAS CHILDRENS|||||5.71||| 73130|EAP|0320|HAND LT.3 VIEWS|Medicare|MEDICARE ACUTE|5.71||||5.71||| 73130|EAP|0320|HAND RT.3 VIEWS|Medicaid|MEDICAID PCCM|||||5.71||| 73130|EAP|0320|HAND RT.3 VIEWS|Medicaid|MEDICAID HMO|||||5.71||| 73130|EAP|0320|HAND LT.3 VIEWS|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||5.71||| 73130|EAP|0320|HAND LT.3 VIEWS|Medicaid|MEDICAID|5.71||||5.71||| 73130|EAP|0320|HAND RT.3 VIEWS|Veterans Affairs|VETERANS ADMINISTRATION|||||5.71||| 73130|EAP|0320|HAND RT.3 VIEWS|Workers Compensation|WORKERS COMPENSATION OTHER|||||5.71||| 73130|EAP|0320|HAND RT.3 VIEWS|Medicare|MEDICARE ACUTE|5.71||||5.71||| 73130|EAP|0320|HAND LT.3 VIEWS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||5.71||| 73130|EAP|0320|HAND RT.3 VIEWS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||5.71||| 73130|EAP|0320|HAND LT.3 VIEWS|United Healthcare|UNITED HEALTHCARE|||||5.71||| 73130|EAP|0320|HAND RT.3 VIEWS|Workers Compensation|UT EMPLOYEE INJURY|||||5.71||| 73130|EAP|0320|HAND LT.3 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|||||5.71||| 73130|EAP|0320|HAND RT.3 VIEWS|United Healthcare|UNITED HEALTHCARE|||||5.71||| 73130|EAP|0320|HAND LT.3 VIEWS|Workers Compensation|WORKERS COMPENSATION OTHER|||||5.71||| 73130|EAP|0320|HAND LT.3 VIEWS|Tricare|TRICARE EAST REGION|||||5.71||| 73130|EAP|0320|HAND RT.3 VIEWS|United Healthcare|UNITED HEALTHCARE OTHER|||||5.71||| 73130|EAP|0320|HAND RT.3 VIEWS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||5.71||| 73130|EAP|0320|HAND RT.3 VIEWS|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||5.71||| 73130|EAP|0320|HAND LT.3 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||5.71||| 73130|EAP|0320|HAND LT.3 VIEWS|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||5.71||| 73130|EAP|0320|HAND RT.3 VIEWS|Aetna|AETNA PPO|||||5.71||| 73130|EAP|0320|HAND RT.3 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||5.71||| 73130|EAP|0320|HAND RT.3 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.71||||5.71||| 73130|EAP|0320|HAND LT.3 VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|||||5.71||| 73130|EAP|0320|HAND LT.3 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.71||||5.71||| 73130|EAP|0320|HAND RT.3 VIEWS|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||5.71||| 73130|EAP|0320|HAND LT.3 VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||5.71||| 73130|EAP|0320|HAND RT.3 VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||5.71||| 73130|EAP|0320|HAND RT.3 VIEWS|Aetna|AETNA OTHER|||||5.71||| 73130|EAP|0320|HAND RT.3 VIEWS|Aenta Medicare Advantage|AETNA MEDICARE MA|||||5.71||| 73130|EAP|0320|HAND RT.3 VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|||||5.71||| 73130|EAP|0320|HAND LT.3 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|5.71||||5.71||| 73130|EAP|0320|HAND RT.3 VIEWS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||5.71||| 73130|EAP|0320|HAND RT.3 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|5.71||||5.71||| 73130|EAP|0320|HAND LT.3 VIEWS|Humana Medicare Advantage|HUMANA MA|||||5.71||| 73130|EAP|0320|HAND RT.3 VIEWS|Humana Medicare Advantage|HUMANA MA|||||5.71||| 73130|EAP|0320|HAND LT.3 VIEWS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||5.71||| 73140|EAP|0320|XR FINGER RT MIN 2 VIEWS|Humana Medicare Advantage|HUMANA MA|||||5.16||| 73140|EAP|0320|XR FINGER LT MIN 2 VIEWS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||5.16||| 73140|EAP|0320|XR FINGER RT MIN 2 VIEWS|Blue Cross PPO Specialty|BCBSTX OTHER|||||5.16||| 73140|EAP|0320|XR FINGER LT MIN 2 VIEWS|Cigna|CIGNA|||||5.16||| 73140|EAP|0320|XR FINGER RT MIN 2 VIEWS|United Healthcare|UNITED HEALTHCARE OTHER|||||5.16||| 73140|EAP|0320|XR FINGER RT MIN 2 VIEWS|United Healthcare|UNITED HEALTHCARE|||||5.16||| 73140|EAP|0320|XR FINGER RT MIN 2 VIEWS|Rusk State Hospital|RUSK STATE HOSP|||||5.16||| 73140|EAP|0320|XR FINGER RT MIN 2 VIEWS|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||5.16||| 73140|EAP|0320|XR FINGER LT MIN 2 VIEWS|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||5.16||| 73140|EAP|0320|XR FINGER RT MIN 2 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|||||5.16||| 73140|EAP|0320|XR FINGER RT MIN 2 VIEWS|Medicaid|MEDICAID|5.16||||||| 73140|EAP|0320|XR FINGER LT MIN 2 VIEWS|United Healthcare|UNITED HEALTHCARE|||||5.16||| 73140|EAP|0320|XR FINGER RT MIN 2 VIEWS|Medicare|MEDICARE ACUTE|5.16||||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|United Medicare Advantage|UHC MEDICARE GOLD MA|||||5.16||| 73140|EAP|0320|XR FINGER RT MIN 2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||5.16||| 73140|EAP|0320|XR FINGER LT MIN 2 VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|||||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 AMERIGROUP|||||5.16||| 73140|EAP|0320|XR FINGER LT MIN 2 VIEWS|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||5.16||| 73140|EAP|0320|XR FINGER RT MIN 2 VIEWS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||5.16||| 73140|EAP|0320|XR FINGER LT MIN 2 VIEWS|Humana Medicare Advantage|HUMANA MA|||||5.16||| 73140|EAP|0320|XR FINGER RT MIN 2 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|5.16||||5.16||| 73200|EAP|0350|EXTREMITY LT.UPPER W/O CO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3,627.75||| 73201|EAP|0350|EXTREMITY RT.UPPER W/CONT|Aetna|AETNA PPO|||||4,738.75||| 73201|EAP|0350|EXTREMITY LT.UPPER W/CONT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||4,738.75||| 73201|EAP|0350|EXTREMITY RT.UPPER W/CONT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||4,738.75||| 73202|EAP|0350|EXTREMITY RT.UPPER W&W/O|Medicare|MEDICARE ACUTE|||||53.74||| 73202|EAP|0350|EXTREMITY LT.UPPER W&W/O|Medicare|MEDICARE ACUTE|||||53.74||| 73202|EAP|0350|EXTREMITY RT.UPPER W&W/O|United Medicare Advantage|UHC MEDICARE GOLD MA|||||53.74||| 73202|EAP|0350|EXTREMITY RT.UPPER W&W/O|Humana Medicare Advantage|HUMANA MA|||||53.74||| 73202|EAP|0350|EXTREMITY LT.UPPER W&W/O|Blue Cross PPO Specialty|BCBSTX PPO|||||53.74||| 73202|EAP|0350|EXTREMITY RT.UPPER W&W/O|Blue Cross HMO Specialty|BCBSTX HMO|||||53.74||| 73202|EAP|0350|EXTREMITY RT.UPPER W&W/O|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||53.74||| 73202|EAP|0350|EXTREMITY RT.UPPER W&W/O|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||53.74||| 73202|EAP|0350|EXTREMITY RT.UPPER W&W/O|United Healthcare|UNITED HEALTHCARE|||||53.74||| 73202|EAP|0350|EXTREMITY LT.UPPER W&W/O|United Medicare Advantage|UHC MEDICARE GOLD MA|||||53.74||| 73206|EAP|0422|CTA ANGIO UPPER EXTREMITY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||32.15||| 73218|EAP|0610|MRI UPPER EXT RT W/O CONT|Blue Cross PPO Specialty|BCBSTX PPO|||||58.50||| 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 UNITED HEALTHCARE|||||58.50||| 73221|EAP|0610|MRI UPPER LT.EXT.JOINT W/|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||58.50||| 73221|EAP|0610|MRI UPPER RT.EXT JOINT W/|NON CONTRACTED|COMMERCIAL OTHER 1|||||58.50||| 73221|EAP|0610|MRI UPPER RT.EXT JOINT W/|Medicaid|MEDICAID|||||58.50||| 73221|EAP|0610|MRI UPPER LT.EXT.JOINT W/|NON CONTRACTED|COMMERCIAL OTHER 1|||||58.50||| 73221|EAP|0610|MRI UPPER RT.EXT JOINT W/|Medicare|MEDICARE ACUTE|||||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 LT.EXT.JOINT W/|United Healthcare|UNITED HEALTHCARE OTHER|||||58.50||| 73221|EAP|0610|MRI UPPER LT.EXT.JOINT W/|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||58.50||| 73221|EAP|0610|MRI UPPER LT.EXT.JOINT W/|Medicare|MEDICARE ACUTE|||||58.50||| 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|||||58.50||| 73221|EAP|0610|MRI UPPER RT.EXT JOINT W/|Aenta Medicare Advantage|AETNA MEDICARE MA|||||58.50||| 73221|EAP|0610|MRI UPPER RT.EXT JOINT W/|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||58.50||| 73221|EAP|0610|MRI UPPER LT.EXT.JOINT W/|Aetna|AETNA OTHER|||||58.50||| 73221|EAP|0610|MRI UPPER RT.EXT JOINT W/|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||58.50||| 73221|EAP|0610|MRI UPPER LT.EXT.JOINT W/|Humana Medicare Advantage|HUMANA MA|||||58.50||| 73221|EAP|0610|MRI UPPER LT.EXT.JOINT W/|Workers Compensation|WORKERS COMPENSATION OTHER|||||58.50||| 73221|EAP|0610|MRI UPPER RT.EXT JOINT W/|Humana Medicare Advantage|HUMANA MA|||||58.50||| 73221|EAP|0610|MRI UPPER RT.EXT JOINT W/|United Medicare Advantage|UHC MEDICARE GOLD MA|||||58.50||| 73221|EAP|0610|MRI UPPER LT.EXT.JOINT W/|Blue Cross PPO Specialty|BCBSTX PPO|||||58.50||| 73221|EAP|0610|MRI UPPER RT.EXT JOINT W/|Blue Cross PPO Specialty|BCBSTX PPO|||||58.50||| 73221|EAP|0610|MRI UPPER LT.EXT.JOINT W/|Blue Cross HMO Specialty|BCBSTX HMO|||||58.50||| 73221|EAP|0610|MRI UPPER RT.EXT JOINT W/|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||58.50||| 73501|EAP|0320|HIP RT 1 VW INC/PELVIS|Blue Cross PPO Specialty|BCBSTX PPO|452.25||||452.25||| 73501|EAP|0320|HIP LT 1 VW INC/PLEVIS|Blue Cross PPO Specialty|BCBSTX PPO|452.25||||452.25||| 73501|EAP|0320|HIP RT 1 VW INC/PELVIS|Humana Medicare Advantage|HUMANA MA|452.25||||452.25||| 73501|EAP|0320|HIP RT 1 VW INC/PELVIS|Aenta Medicare Advantage|AETNA MEDICARE MA|452.25||||||| 73501|EAP|0320|HIP LT 1 VW INC/PLEVIS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|452.25||||||| 73501|EAP|0320|HIP RT 1 VW INC/PELVIS|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|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|Medicare|MEDICARE ACUTE|452.25||||452.25||| 73501|EAP|0320|HIP RT 1 VW INC/PELVIS|NON CONTRACTED|COMMERCIAL OTHER 1|452.25||||||| 73501|EAP|0320|HIP RT 1 VW INC/PELVIS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||452.25||| 73502|EAP|0320|HIP LT 2VW INC/PELVIS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||515.75||| 73502|EAP|0320|HIP RT 2VW INC/PELVIS|Managed Medicaid|MEDICAID SUPERIOR|515.75||||515.75||| 73502|EAP|0320|HIP LT 2VW INC/PELVIS|Managed Medicaid|MEDICAID AMERIGROUP|||||515.75||| 73502|EAP|0320|HIP LT 2VW INC/PELVIS|Managed Medicaid|MEDICAID SUPERIOR|515.75||||515.75||| 73502|EAP|0320|HIP LT 2VW INC/PELVIS|Managed Medicare|HEALTHSPRING MA|||||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 CIGNA HEALTHSPRING|||||515.75||| 73502|EAP|0320|HIP LT 2VW INC/PELVIS|UTMB|UTMB CORRECTIONAL MANAGED CARE|515.75||||515.75||| 73502|EAP|0320|HIP LT 2VW INC/PELVIS|Medicaid|MEDICAID|515.75||||||| 73502|EAP|0320|HIP LT 2VW INC/PELVIS|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||515.75||| 73502|EAP|0320|HIP LT 2VW INC/PELVIS|Tricare|TRICARE EAST REGION|||||515.75||| 73502|EAP|0320|HIP RT 2VW INC/PELVIS|NON CONTRACTED|COMMERCIAL OTHER 1|515.75||||515.75||| 73502|EAP|0320|HIP LT 2VW INC/PELVIS|NON CONTRACTED|COMMERCIAL OTHER 1|515.75||||515.75||| 73502|EAP|0320|HIP RT 2VW INC/PELVIS|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||515.75||| 73502|EAP|0320|HIP RT 2VW INC/PELVIS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|515.75||||515.75||| 73502|EAP|0320|HIP LT 2VW INC/PELVIS|United Medicare Advantage|UHC MEDICARE GOLD MA|515.75||||515.75||| 73502|EAP|0320|HIP RT 2VW INC/PELVIS|Veterans Affairs|VETERANS ADMINISTRATION|||||515.75||| 73502|EAP|0320|HIP LT 2VW INC/PELVIS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|515.75||||515.75||| 73502|EAP|0320|HIP RT 2VW INC/PELVIS|United Medicare Advantage|UHC MEDICARE GOLD MA|515.75||||515.75||| 73502|EAP|0320|HIP RT 2VW INC/PELVIS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||515.75||| 73502|EAP|0320|HIP RT 2VW INC/PELVIS|Blue Cross HMO Specialty|BCBSTX HMO|||||515.75||| 73502|EAP|0320|HIP RT 2VW INC/PELVIS|Rusk State Hospital|RUSK STATE HOSP|||||515.75||| 73502|EAP|0320|HIP RT 2VW INC/PELVIS|Aenta Medicare Advantage|AETNA MEDICARE MA|515.75||||515.75||| 73502|EAP|0320|HIP RT 2VW INC/PELVIS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||515.75||| 73502|EAP|0320|HIP LT 2VW INC/PELVIS|Medicare|MEDICARE ACUTE|515.75||||515.75||| 73502|EAP|0320|HIP RT 2VW INC/PELVIS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||515.75||| 73502|EAP|0320|HIP LT 2VW INC/PELVIS|Aenta Medicare Advantage|AETNA MEDICARE MA|515.75||||515.75||| 73502|EAP|0320|HIP RT 2VW INC/PELVIS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||515.75||| 73502|EAP|0320|HIP RT 2VW INC/PELVIS|Medicare|MEDICARE ACUTE|515.75||||515.75||| 73502|EAP|0320|HIP LT 2VW INC/PELVIS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||515.75||| 73502|EAP|0320|HIP LT 2VW INC/PELVIS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||515.75||| 73502|EAP|0320|HIP LT 2VW INC/PELVIS|Humana Medicare Advantage|HUMANA MA|515.75||||515.75||| 73502|EAP|0320|HIP LT 2VW INC/PELVIS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||515.75||| 73502|EAP|0320|HIP RT 2VW INC/PELVIS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||515.75||| 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||||515.75||| 73502|EAP|0320|HIP RT 2VW INC/PELVIS|Humana Medicare Advantage|HUMANA MA|515.75||||515.75||| 73502|EAP|0320|HIP RT 2VW INC/PELVIS|Cigna|CIGNA|||||515.75||| 73521|EAP|0320|HIP BILATERAL INC/PELVIS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||538.50||| 73521|EAP|0320|HIP BILATERAL INC/PELVIS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||538.50||| 73521|EAP|0320|HIP BILATERAL INC/PELVIS|Medicaid|MEDICAID|5.71||||538.50||| 73521|EAP|0320|HIP BILATERAL INC/PELVIS|Managed Medicaid|MEDICAID AMERIGROUP|||||538.50||| 73521|EAP|0320|HIP BILATERAL INC/PELVIS|Managed Medicaid|MEDICAID SUPERIOR|||||538.50||| 73521|EAP|0320|HIP BILATERAL INC/PELVIS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||538.50||| 73521|EAP|0320|HIPS W PELVIS INFANT 2 VI|Managed Medicaid|MEDICAID AMERIGROUP|||||5.71||| 73522|EAP|0320|HIP BILATERAL INC/PELVIS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||7.00||| 73522|EAP|0320|HIP BILATERAL INC/PELVIS|Medicare|MEDICARE ACUTE|7.00||||||| 73522|EAP|0320|HIP BILATERAL INC/PELVIS|Humana Medicare Advantage|HUMANA MA|7.00||||||| 73522|EAP|0320|HIP BILATERAL INC/PELVIS|Blue Cross PPO Specialty|BCBSTX PPO|||||7.00||| 73522|EAP|0320|HIP BILATERAL INC/PELVIS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||7.00||| 73523|EAP|0320|HIP BILATERAL INC/PELVIS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||8.00||| 73523|EAP|0320|HIP BILATERAL INC/PELVIS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||8.00||| 73523|EAP|0320|HIP BILATERAL INC/PELVIS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||8.00||| 73523|EAP|0320|HIP BILATERAL INC/PELVIS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||8.00||| 73523|EAP|0320|HIP BILATERAL INC/PELVIS|Humana Medicare Advantage|HUMANA MA|||||8.00||| 73523|EAP|0320|HIP BILATERAL INC/PELVIS|Medicare|MEDICARE ACUTE|||||8.00||| 73523|EAP|0320|HIP BILATERAL INC/PELVIS|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||8.00||| 73523|EAP|0320|HIP BILATERAL INC/PELVIS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||8.00||| 73523|EAP|0320|HIP BILATERAL INC/PELVIS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||8.00||| 73523|EAP|0320|HIP BILATERAL INC/PELVIS|Managed Medicaid|MEDICAID AMERIGROUP|||||8.00||| 73523|EAP|0320|HIP BILATERAL INC/PELVIS|Managed Medicaid|MEDICAID SUPERIOR|||||8.00||| 73551|EAP|0320|XR FEMUR LT 1 VIEW|Managed Medicaid|MEDICAID AMERIGROUP|||||5.16||| 73551|EAP|0320|XR FEMUR LT 1 VIEW|Medicaid|MEDICAID|||||5.16||| 73551|EAP|0320|XR FEMUR RT 1 VIEW|Blue Cross PPO Specialty|BCBSTX PPO|||||5.16||| 73551|EAP|0320|XR FEMUR LT 1 VIEW|Blue Cross PPO Specialty|BCBSTX PPO|||||5.16||| 73551|EAP|0320|XR FEMUR RT 1 VIEW|Aetna|AETNA OTHER|||||5.16||| 73551|EAP|0320|XR FEMUR LT 1 VIEW|Aetna|AETNA OTHER|||||5.16||| 73552|EAP|0320|FEMUR RT.2 VIEWS|Workers Compensation|WORKERS COMPENSATION OTHER|515.75||||||| 73552|EAP|0320|FEMUR LT.2 VIEWS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||515.75||| 73552|EAP|0320|FEMUR LT.2 VIEWS|United Healthcare|UNITED HEALTHCARE|||||515.75||| 73552|EAP|0320|FEMUR RT.2 VIEWS|United Healthcare|UNITED HEALTHCARE|||||515.75||| 73552|EAP|0320|FEMUR RT.2 VIEWS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||515.75||| 73552|EAP|0320|FEMUR LT.2 VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||515.75||| 73552|EAP|0320|FEMUR LT.2 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|515.75||||||| 73552|EAP|0320|FEMUR LT.2 VIEWS|Humana Medicare Advantage|HUMANA MA|515.75||||515.75||| 73552|EAP|0320|FEMUR LT.2 VIEWS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||515.75||| 73552|EAP|0320|FEMUR LT.2 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||515.75||| 73552|EAP|0320|FEMUR RT.2 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||515.75||| 73552|EAP|0320|FEMUR RT.2 VIEWS|Humana Medicare Advantage|HUMANA MA|515.75||||515.75||| 73552|EAP|0320|FEMUR RT.2 VIEWS|Medicare|MEDICARE ACUTE|515.75||||515.75||| 73552|EAP|0320|FEMUR LT.2 VIEWS|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||515.75||| 73552|EAP|0320|FEMUR LT.2 VIEWS|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||515.75||| 73552|EAP|0320|FEMUR RT.2 VIEWS|Rusk State Hospital|RUSK STATE HOSP|||||515.75||| 73552|EAP|0320|FEMUR RT.2 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||515.75||| 73552|EAP|0320|FEMUR LT.2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||515.75||| 73552|EAP|0320|FEMUR LT.2 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||515.75||| 73560|EAP|0320|XR KNEE LT 1 VIEW|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|452.25||||||| 73560|EAP|0320|KNEE LT.2 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|452.25||||||| 73560|EAP|0320|KNEE RT. 2 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|452.25||||||| 73560|EAP|0320|XR KNEE RT 1 VIEW|Managed Medicare|HEALTHSPRING MA|||||452.25||| 73560|EAP|0320|KNEE LT.2 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||452.25||| 73560|EAP|0320|KNEE RT. 2 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||452.25||| 73560|EAP|0320|KNEE RT. 2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||452.25||| 73560|EAP|0320|KNEE LT.2 VIEWS|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||452.25||| 73560|EAP|0320|KNEE RT. 2 VIEWS|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||452.25||| 73560|EAP|0320|KNEE RT. 2 VIEWS|Medicare|MEDICARE ACUTE|452.25||||452.25||| 73560|EAP|0320|KNEE LT.2 VIEWS|Medicare|MEDICARE ACUTE|452.25||||452.25||| 73560|EAP|0320|XR KNEE RT 1 VIEW|Blue Cross PPO Specialty|BCBSTX PPO|452.25||||452.25||| 73560|EAP|0320|KNEE LT.2 VIEWS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|452.25||||||| 73560|EAP|0320|KNEE RT. 2 VIEWS|Tricare|TRICARE EAST REGION|452.25||||||| 73560|EAP|0320|KNEE RT. 2 VIEWS|Cigna|CIGNA|452.25||||||| 73560|EAP|0320|KNEE RT. 2 VIEWS|Humana Medicare Advantage|HUMANA MA|452.25||||452.25||| 73560|EAP|0320|KNEE LT.2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||452.25||| 73560|EAP|0320|KNEE LT.2 VIEWS|Humana Medicare Advantage|HUMANA MA|452.25||||452.25||| 73560|EAP|0320|KNEE RT. 2 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|452.25||||452.25||| 73560|EAP|0320|KNEE LT.2 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|452.25||||||| 73560|EAP|0320|KNEE RT. 2 VIEWS|Aenta Medicare Advantage|AETNA MEDICARE MA|452.25||||||| 73560|EAP|0320|KNEE RT. 2 VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|452.25||||||| 73560|EAP|0320|KNEE RT. 2 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|452.25||||||| 73560|EAP|0320|KNEE RT. 2 VIEWS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|452.25||||||| 73560|EAP|0320|KNEE LT.2 VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|452.25||||||| 73560|EAP|0320|KNEE RT. 2 VIEWS|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|452.25||||||| 73560|EAP|0320|KNEE RT. 2 VIEWS|Workers Compensation|WORKERS COMPENSATION OTHER|452.25||||452.25||| 73560|EAP|0320|KNEE LT.2 VIEWS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|452.25||||452.25||| 73560|EAP|0320|KNEE RT. 2 VIEWS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|452.25||||452.25||| 73560|EAP|0320|KNEE RT. 2 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||452.25||| 73560|EAP|0320|KNEE LT.2 VIEWS|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||452.25||| 73560|EAP|0320|KNEE LT.2 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||452.25||| 73560|EAP|0320|KNEE RT. 2 VIEWS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|452.25||||452.25||| 73560|EAP|0320|XR KNEE RT 1 VIEW|United Medicare Advantage|UHC MEDICARE GOLD MA|||||452.25||| 73560|EAP|0320|XR KNEE RT 1 VIEW|Workers Compensation|WORKERS COMPENSATION OTHER|452.25||||452.25||| 73562|EAP|0320|KNEE LT.3 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||5.71||| 73562|EAP|0320|KNEE RT. 3 VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|||||5.71||| 73562|EAP|0320|KNEE RT. 3 VIEWS|Humana Medicare Advantage|HUMANA MA|||||5.71||| 73562|EAP|0320|KNEE LT.3 VIEWS|Humana Medicare Advantage|HUMANA MA|||||5.71||| 73562|EAP|0320|KNEE LT.3 VIEWS|Medicare|MEDICARE ACUTE|||||5.71||| 73562|EAP|0320|KNEE RT. 3 VIEWS|Medicaid|MEDICAID|||||5.71||| 73562|EAP|0320|KNEE RT. 3 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|||||5.71||| 73562|EAP|0320|KNEE LT.3 VIEWS|Medicaid|MEDICAID|||||5.71||| 73562|EAP|0320|KNEE LT.3 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||5.71||| 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||| 73564|EAP|0320|KNEE 4 VIEW RIGHT|Managed Medicaid|MEDICAID SUPERIOR|||||6.27||| 73564|EAP|0320|XR KNEE LT 4 VIEWS OR MOR|Managed Medicaid|MEDICAID SUPERIOR|||||618.75||| 73564|EAP|0320|KNEE 4 VIEW RIGHT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||6.27||| 73564|EAP|0320|XR KNEE LT 4 VIEWS OR MOR|Managed Medicare|HEALTHSPRING MA|||||618.75||| 73564|EAP|0320|XR KNEE LT 4 VIEWS OR MOR|Managed Medicaid|MEDICAID AMERIGROUP|||||618.75||| 73564|EAP|0320|XR KNEE LT 4 VIEWS OR MOR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||618.75||| 73564|EAP|0320|KNEE 4 VIEW RIGHT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||6.27||| 73564|EAP|0320|KNEE 4 VIEW RIGHT|Managed Medicaid|MEDICAID AMERIGROUP|||||6.27||| 73564|EAP|0320|KNEE 4 VIEW RIGHT|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||6.27||| 73564|EAP|0320|XR KNEE LT 4 VIEWS OR MOR|Tricare|TRICARE EAST REGION|||||618.75||| 73564|EAP|0320|KNEE 4 VIEW RIGHT|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||6.27||| 73564|EAP|0320|XR KNEE LT 4 VIEWS OR MOR|Tricare|TRICARE FOR LIFE|||||618.75||| 73564|EAP|0320|XR KNEE LT 4 VIEWS OR MOR|NON CONTRACTED|COMMERCIAL OTHER 1|||||618.75||| 73564|EAP|0320|XR KNEE LT 4 VIEWS OR MOR|Medicare|MEDICARE ACUTE|618.75||||618.75||| 73564|EAP|0320|KNEE 4 VIEW RIGHT|NON CONTRACTED|COMMERCIAL OTHER 1|||||6.27||| 73564|EAP|0320|XR KNEE LT 4 VIEWS OR MOR|Rusk State Hospital|RUSK STATE HOSP|||||618.75||| 73564|EAP|0320|KNEE 4 VIEW RIGHT|Tricare|TRICARE EAST REGION|||||6.27||| 73564|EAP|0320|KNEE 4 VIEW RIGHT|Blue Cross PPO Specialty|BCBSTX OTHER|||||6.27||| 73564|EAP|0320|KNEE 4 VIEW RIGHT|Cigna|CIGNA|||||6.27||| 73564|EAP|0320|XR KNEE LT 4 VIEWS OR MOR|Humana Medicare Advantage|HUMANA MA|618.75||||618.75||| 73564|EAP|0320|KNEE 4 VIEW RIGHT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||6.27||| 73564|EAP|0320|KNEE 4 VIEW RIGHT|Humana Medicare Advantage|HUMANA MA|618.75||||6.27||| 73564|EAP|0320|XR KNEE LT 4 VIEWS OR MOR|Cigna|CIGNA|||||618.75||| 73564|EAP|0320|KNEE 4 VIEW RIGHT|Blue Cross PPO Specialty|BCBSTX PPO|||||6.27||| 73564|EAP|0320|XR KNEE LT 4 VIEWS OR MOR|Blue Cross PPO Specialty|BCBSTX PPO|||||618.75||| 73564|EAP|0320|XR KNEE LT 4 VIEWS OR MOR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||618.75||| 73564|EAP|0320|XR KNEE LT 4 VIEWS OR MOR|Aetna|AETNA OTHER|||||618.75||| 73564|EAP|0320|KNEE 4 VIEW RIGHT|Blue Cross HMO Specialty|BCBSTX HMO|||||6.27||| 73564|EAP|0320|KNEE 4 VIEW RIGHT|Medicare|MEDICARE ACUTE|618.75||||6.27||| 73564|EAP|0320|XR KNEE LT 4 VIEWS OR MOR|Medicaid|MEDICAID|||||618.75||| 73564|EAP|0320|XR KNEE LT 4 VIEWS OR MOR|Blue Cross HMO Specialty|BCBSTX HMO|||||618.75||| 73564|EAP|0320|KNEE 4 VIEW RIGHT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6.27||| 73564|EAP|0320|XR KNEE LT 4 VIEWS OR MOR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||618.75||| 73564|EAP|0320|XR KNEE LT 4 VIEWS OR MOR|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||618.75||| 73564|EAP|0320|KNEE 4 VIEW RIGHT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||6.27||| 73564|EAP|0320|KNEE 4 VIEW RIGHT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||6.27||| 73564|EAP|0320|KNEE 4 VIEW RIGHT|Aenta Medicare Advantage|AETNA MEDICARE MA|||||6.27||| 73564|EAP|0320|XR KNEE LT 4 VIEWS OR MOR|Aenta Medicare Advantage|AETNA MEDICARE MA|||||618.75||| 73564|EAP|0320|XR KNEE LT 4 VIEWS OR MOR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||618.75||| 73564|EAP|0320|XR KNEE LT 4 VIEWS OR MOR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||618.75||| 73564|EAP|0320|KNEE 4 VIEW RIGHT|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||6.27||| 73564|EAP|0320|KNEE 4 VIEW RIGHT|Veterans Affairs|VETERANS ADMINISTRATION|||||6.27||| 73564|EAP|0320|XR KNEE LT 4 VIEWS OR MOR|Workers Compensation|WORKERS COMPENSATION OTHER|||||618.75||| 73564|EAP|0320|KNEE 4 VIEW RIGHT|United Healthcare|UNITED HEALTHCARE OTHER|||||6.27||| 73564|EAP|0320|KNEE 4 VIEW RIGHT|United Medicare Advantage|UHC MEDICARE GOLD MA|6.27||||6.27||| 73564|EAP|0320|KNEE 4 VIEW RIGHT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||6.27||| 73564|EAP|0320|KNEE 4 VIEW RIGHT|United Healthcare|UNITED HEALTHCARE|||||6.27||| 73564|EAP|0320|XR KNEE LT 4 VIEWS OR MOR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||618.75||| 73564|EAP|0320|XR KNEE LT 4 VIEWS OR MOR|United Healthcare|UNITED HEALTHCARE|||||618.75||| 73564|EAP|0320|XR KNEE LT 4 VIEWS OR MOR|Workers Compensation|UT EMPLOYEE INJURY|||||618.75||| 73564|EAP|0320|XR KNEE LT 4 VIEWS OR MOR|United Medicare Advantage|UHC MEDICARE GOLD MA|6.27||||618.75||| 73564|EAP|0320|XR KNEE LT 4 VIEWS OR MOR|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||618.75||| 73564|EAP|0320|KNEE 4 VIEW RIGHT|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||6.27||| 73565|EAP|0320|KNEE BILATERAL WEIGHT BEA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||5.71||| 73565|EAP|0320|KNEE BILATERAL WEIGHT BEA|United Medicare Advantage|UHC MEDICARE GOLD MA|||||5.71||| 73565|EAP|0320|KNEE BILATERAL WEIGHT BEA|Blue Cross HMO Specialty|BCBSTX HMO|||||5.71||| 73565|EAP|0320|KNEE BILATERAL WEIGHT BEA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||5.71||| 73565|EAP|0320|KNEE BILATERAL WEIGHT BEA|Blue Cross PPO Specialty|BCBSTX PPO|||||5.71||| 73565|EAP|0320|KNEE BILATERAL WEIGHT BEA|Humana Medicare Advantage|HUMANA MA|||||5.71||| 73565|EAP|0320|KNEE BILATERAL WEIGHT BEA|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||5.71||| 73565|EAP|0320|KNEE BILATERAL WEIGHT BEA|Medicaid|MEDICAID TEXAS CHILDRENS|||||5.71||| 73565|EAP|0320|KNEE BILATERAL WEIGHT BEA|Medicare|MEDICARE ACUTE|||||5.71||| 73565|EAP|0320|KNEE BILATERAL WEIGHT BEA|NON CONTRACTED|COMMERCIAL OTHER 1|||||5.71||| 73565|EAP|0320|KNEE BILATERAL WEIGHT BEA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||5.71||| 73565|EAP|0320|KNEE BILATERAL WEIGHT BEA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||5.71||| 73565|EAP|0320|KNEE BILATERAL WEIGHT BEA|Managed Medicaid|MEDICAID AMERIGROUP|||||5.71||| 73590|EAP|0320|LEG LT.2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||515.75||| 73590|EAP|0320|LEG RT. 2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||515.75||| 73590|EAP|0320|XR LEG LT 1 VIEW|Managed Medicaid|MEDICAID AMERIGROUP|||||5.16||| 73590|EAP|0320|LEG LT.2 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||515.75||| 73590|EAP|0320|LEG LT.2 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||515.75||| 73590|EAP|0320|LEG RT. 2 VIEWS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||515.75||| 73590|EAP|0320|LEG RT. 2 VIEWS|Medicare|MEDICARE ACUTE|515.75||||515.75||| 73590|EAP|0320|XR LEG LT 1 VIEW|Medicare|MEDICARE ACUTE|515.75||||5.16||| 73590|EAP|0320|LEG LT.2 VIEWS|Medicaid|MEDICAID|||||515.75||| 73590|EAP|0320|LEG LT.2 VIEWS|Medicare|MEDICARE ACUTE|515.75||||515.75||| 73590|EAP|0320|LEG LT.2 VIEWS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||515.75||| 73590|EAP|0320|LEG RT. 2 VIEWS|Cigna|CIGNA|||||515.75||| 73590|EAP|0320|XR LEG LT 1 VIEW|Medicaid|MEDICAID|||||5.16||| 73590|EAP|0320|LEG RT. 2 VIEWS|Blue Cross PPO Specialty|BCBSTX OTHER|||||515.75||| 73590|EAP|0320|XR LEG LT 1 VIEW|Blue Cross PPO Specialty|BCBSTX PPO|515.75||||5.16||| 73590|EAP|0320|LEG LT.2 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|515.75||||515.75||| 73590|EAP|0320|LEG RT. 2 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|515.75||||515.75||| 73590|EAP|0320|XR LEG RT 1 VIEW|Blue Cross PPO Specialty|BCBSTX PPO|515.75||||5.16||| 73590|EAP|0320|LEG LT.2 VIEWS|Humana Medicare Advantage|HUMANA MA|515.75||||515.75||| 73590|EAP|0320|LEG LT.2 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||515.75||| 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|XR LEG LT 1 VIEW|Aetna|AETNA OTHER|||||5.16||| 73590|EAP|0320|LEG RT. 2 VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|||||515.75||| 73590|EAP|0320|LEG RT. 2 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|515.75||||515.75||| 73590|EAP|0320|XR LEG RT 1 VIEW|Aetna|AETNA OTHER|||||5.16||| 73590|EAP|0320|LEG LT.2 VIEWS|United Healthcare|UNITED HEALTHCARE|||||515.75||| 73590|EAP|0320|LEG RT. 2 VIEWS|United Healthcare|TML GROUP BENEFITS|||||515.75||| 73590|EAP|0320|LEG RT. 2 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||515.75||| 73590|EAP|0320|LEG LT.2 VIEWS|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||515.75||| 73590|EAP|0320|LEG LT.2 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||515.75||| 73590|EAP|0320|LEG LT.2 VIEWS|Workers Compensation|WORKERS COMPENSATION OTHER|515.75||||515.75||| 73592|EAP|0320|EXTREMITY RT.LOWER INFANT|Medicaid|MEDICAID|||||5.71||| 73592|EAP|0320|EXTREMITY LT.LOWER INFANT|Medicaid|MEDICAID|||||5.71||| 73600|EAP|0320|ANKLE RT.2 VIEWS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||515.75||| 73600|EAP|0320|ANKLE LT.2 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||515.75||| 73600|EAP|0320|ANKLE RT.2 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||515.75||| 73600|EAP|0320|ANKLE RT.2 VIEWS|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||515.75||| 73600|EAP|0320|ANKLE LT.2 VIEWS|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||515.75||| 73600|EAP|0320|ANKLE RT.2 VIEWS|Medicare|MEDICARE ACUTE|515.75||||||| 73610|EAP|0320|ANKLE LT.COMP 3 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||5.71||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||5.71||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||5.71||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||5.71||| 73610|EAP|0320|ANKLE LT.COMP 3 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||5.71||| 73610|EAP|0320|ANKLE LT.COMP 3 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||5.71||| 73610|EAP|0320|ANKLE LT.COMP 3 VIEWS|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||5.71||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||5.71||| 73610|EAP|0320|ANKLE LT.COMP 3 VIEWS|Medicaid|MEDICAID PCCM|||||5.71||| 73610|EAP|0320|ANKLE LT.COMP 3 VIEWS|Medicare|MEDICARE ACUTE|5.71||||5.71||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|Medicaid|MEDICAID HMO|||||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|Medicare|MEDICARE ACUTE|5.71||||5.71||| 73610|EAP|0320|ANKLE LT.COMP 3 VIEWS|Medicaid|MEDICAID|5.71||||5.71||| 73610|EAP|0320|ANKLE LT.COMP 3 VIEWS|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||5.71||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|Tricare|TRICARE EAST REGION|||||5.71||| 73610|EAP|0320|ANKLE LT.COMP 3 VIEWS|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||5.71||| 73610|EAP|0320|ANKLE LT.COMP 3 VIEWS|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||5.71||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|Medicaid|MEDICAID|5.71||||5.71||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||5.71||| 73610|EAP|0320|ANKLE LT.COMP 3 VIEWS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||5.71||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||5.71||| 73610|EAP|0320|ANKLE LT.COMP 3 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||5.71||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||5.71||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|Medicaid|MEDICAID TEXAS CHILDRENS|||||5.71||| 73610|EAP|0320|ANKLE LT.COMP 3 VIEWS|Humana Medicare Advantage|HUMANA MA|5.71||||5.71||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|Humana Medicare Advantage|HUMANA MA|5.71||||5.71||| 73610|EAP|0320|ANKLE LT.COMP 3 VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||5.71||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||5.71||| 73610|EAP|0320|ANKLE RT.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 TPA UTH UMR|||||5.71||| 73610|EAP|0320|ANKLE LT.COMP 3 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||5.71||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|Aetna|AETNA OTHER|||||5.71||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||5.71||| 73610|EAP|0320|ANKLE LT.COMP 3 VIEWS|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||5.71||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|||||5.71||| 73610|EAP|0320|ANKLE LT.COMP 3 VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|||||5.71||| 73610|EAP|0320|ANKLE LT.COMP 3 VIEWS|Aenta Medicare Advantage|AETNA MEDICARE MA|||||5.71||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||5.71||| 73610|EAP|0320|ANKLE LT.COMP 3 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||5.71||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|Veterans Affairs|VETERANS ADMINISTRATION|||||5.71||| 73610|EAP|0320|ANKLE LT.COMP 3 VIEWS|United Healthcare|TML GROUP BENEFITS|||||5.71||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|Workers Compensation|WORKERS COMPENSATION OTHER|||||5.71||| 73610|EAP|0320|ANKLE LT.COMP 3 VIEWS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP 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 LT.COMP 3 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|5.71||||5.71||| 73610|EAP|0320|ANKLE LT.COMP 3 VIEWS|United Healthcare|UNITED HEALTHCARE|||||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 GOLD MA|5.71||||5.71||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||5.71||| 73610|EAP|0320|ANKLE LT.COMP 3 VIEWS|United Healthcare|UNITED HEALTHCARE OTHER|||||5.71||| 73610|EAP|0320|ANKLE RT.COMP 3 VIEWS|United Healthcare|UNITED HEALTHCARE|||||5.71||| 73620|EAP|0320|FOOT LT.2 VIEWS|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||515.75||| 73620|EAP|0320|FOOT RT.2 VIEWS|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||515.75||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|Workers Compensation|WORKERS COMPENSATION OTHER|||||5.71||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|Workers Compensation|WORKERS COMPENSATION OTHER|||||5.71||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|Veterans Affairs|VETERANS ADMINISTRATION|||||5.71||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||5.71||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|United Healthcare|UNITED HEALTHCARE OTHER|||||5.71||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||5.71||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||5.71||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||5.71||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|United Healthcare|TML GROUP BENEFITS|||||5.71||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||5.71||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||5.71||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|||||5.71||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|||||5.71||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|Aenta Medicare Advantage|AETNA MEDICARE MA|||||5.71||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||5.71||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||5.71||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|Aetna|AETNA PPO|||||5.71||| 73630|EAP|0320|FOOT LT.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||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|Aetna|AETNA OTHER|||||5.71||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||5.71||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||5.71||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|Blue Cross PPO Specialty|BCBSTX OTHER|||||5.71||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|Cigna|CIGNA|||||5.71||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|Humana Medicare Advantage|HUMANA MA|||||5.71||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||5.71||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|Humana Medicare Advantage|HUMANA MA|||||5.71||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||5.71||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||5.71||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||5.71||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||5.71||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||5.71||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.71||||5.71||| 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 UNITED HEALTHCARE|5.71||||5.71||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||5.71||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||5.71||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|United Healthcare|UNITED HEALTHCARE|||||5.71||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||5.71||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||5.71||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|Medicare|MEDICARE ACUTE|||||5.71||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|Tricare|TRICARE EAST REGION|||||5.71||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||5.71||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||5.71||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|Medicaid|MEDICAID TEXAS CHILDRENS|||||5.71||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|Medicaid|MEDICAID|5.71||||5.71||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|Medicare|MEDICARE ACUTE|||||5.71||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||5.71||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||5.71||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||5.71||| 73630|EAP|0320|FOOT RT.COMP 3 VIEWS|Tricare|TRICARE EAST REGION|||||5.71||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||5.71||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|Medicaid|MEDICAID|5.71||||5.71||| 73630|EAP|0320|FOOT LT.COMP 3 VIEWS|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||5.71||| 73650|EAP|0320|OS CALCIS LT.2 VIEWS|Medicare|MEDICARE ACUTE|||||515.75||| 73650|EAP|0320|OS CALCIS RT. 2 VIEWS|Medicare|MEDICARE ACUTE|||||515.75||| 73650|EAP|0320|OS CALCIS RT. 2 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|||||515.75||| 73650|EAP|0320|OS CALCIS LT.2 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|||||515.75||| 73650|EAP|0320|OS CALCIS LT.2 VIEWS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||515.75||| 73650|EAP|0320|OS CALCIS RT. 2 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||515.75||| 73650|EAP|0320|OS CALCIS RT. 2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||515.75||| 73650|EAP|0320|OS CALCIS LT.2 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||515.75||| 73650|EAP|0320|OS CALCIS RT. 2 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||515.75||| 73650|EAP|0320|OS CALCIS LT.2 VIEWS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||515.75||| 73650|EAP|0320|OS CALCIS LT.2 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||515.75||| 73650|EAP|0320|OS CALCIS LT.2 VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|||||515.75||| 73660|EAP|0320|XR TOE LEFT|Blue Cross HMO Specialty|BCBSTX HMO|||||5.16||| 73660|EAP|0320|XR TOE LEFT|Aetna|ZZZZZ AETNA|||||5.16||| 73660|EAP|0320|XR TOE RIGHT|Blue Cross HMO Specialty|BCBSTX HMO|||||5.16||| 73660|EAP|0320|XR TOE RIGHT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||5.16||| 73660|EAP|0320|XR TOE RIGHT|Humana Medicare Advantage|HUMANA MA|||||5.16||| 73660|EAP|0320|XR TOE LEFT|Managed Medicaid|MEDICAID SUPERIOR|||||5.16||| 73660|EAP|0320|XR TOE RIGHT|Managed Medicaid|MEDICAID SUPERIOR|||||5.16||| 73660|EAP|0320|XR TOE RIGHT|Managed Medicaid|MEDICAID AMERIGROUP|||||5.16||| 73660|EAP|0320|XR TOE LEFT|Managed Medicaid|MEDICAID AMERIGROUP|||||5.16||| 73660|EAP|0320|XR TOE RIGHT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||5.16||| 73660|EAP|0320|XR TOE LEFT|Medicare|MEDICARE ACUTE|||||5.16||| 73660|EAP|0320|XR TOE RIGHT|Medicare|MEDICARE ACUTE|||||5.16||| 73700|EAP|0350|EXTREMITY RT.LOWER W/O CO|Medicare|MEDICARE ACUTE|3,627.75||||3,627.75||| 73700|EAP|0350|EXTREMITY RT.LOWER W/O CO|Tricare|TRICARE EAST REGION|||||3,627.75||| 73700|EAP|0350|EXTREMITY RT.LOWER W/O CO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||3,627.75||| 73700|EAP|0350|EXTREMITY LT.LOWER W/O CO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||3,627.75||| 73700|EAP|0350|EXTREMITY RT.LOWER W/O CO|Managed Medicaid|MEDICAID AMERIGROUP|||||3,627.75||| 73700|EAP|0350|EXTREMITY RT.LOWER W/O CO|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||3,627.75||| 73700|EAP|0350|EXTREMITY RT.LOWER W/O CO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||3,627.75||| 73700|EAP|0350|EXTREMITY RT.LOWER W/O CO|Workers Compensation|WORKERS COMPENSATION OTHER|3,627.75||||||| 73700|EAP|0350|EXTREMITY RT.LOWER W/O CO|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||3,627.75||| 73700|EAP|0350|EXTREMITY LT.LOWER W/O CO|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||3,627.75||| 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 LT.LOWER W/O CO|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||3,627.75||| 73700|EAP|0350|EXTREMITY LT.LOWER W/O CO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||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 LT.LOWER W/O CO|United Medicare Advantage|UHC MEDICARE GOLD MA|||||3,627.75||| 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|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||3,627.75||| 73700|EAP|0350|EXTREMITY LT.LOWER W/O CO|Humana Medicare Advantage|HUMANA MA|3,627.75||||3,627.75||| 73700|EAP|0350|EXTREMITY RT.LOWER W/O CO|Blue Cross PPO Specialty|BCBSTX PPO|||||3,627.75||| 73700|EAP|0350|EXTREMITY LT.LOWER W/O CO|Blue Cross PPO Specialty|BCBSTX PPO|||||3,627.75||| 73700|EAP|0350|EXTREMITY RT.LOWER W/O CO|Humana Medicare Advantage|HUMANA MA|3,627.75||||3,627.75||| 73700|EAP|0350|EXTREMITY RT.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 HMO Specialty|BCBSTX HMO|||||3,627.75||| 73700|EAP|0350|EXTREMITY RT.LOWER W/O CO|Aenta Medicare Advantage|AETNA MEDICARE MA|||||3,627.75||| 73700|EAP|0350|EXTREMITY LT.LOWER W/O CO|Blue Cross HMO Specialty|BCBSTX HMO|||||3,627.75||| 73700|EAP|0350|EXTREMITY LT.LOWER W/O CO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3,627.75||| 73701|EAP|0350|EXTREMITY RT LOWER W/CONT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4,738.75||||||| 73701|EAP|0350|EXTREMITY RT LOWER W/CONT|Blue Cross PPO Specialty|BCBSTX PPO|||||4,738.75||| 73701|EAP|0350|EXTREMITY RT LOWER W/CONT|United Healthcare|UNITED HEALTHCARE|||||4,738.75||| 73701|EAP|0350|EXTREMITY RT LOWER W/CONT|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||4,738.75||| 73701|EAP|0350|EXTREMITY LT.LOWER W/CONT|Workers Compensation|WORKERS COMPENSATION OTHER|||||4,738.75||| 73701|EAP|0350|EXTREMITY LT.LOWER W/CONT|Medicaid|MEDICAID|4,738.75||||||| 73706|EAP|0350|CTA ANGIO LOWER EXTREMITY|Medicare|MEDICARE ACUTE|3,430.25||||3,430.25||| 73706|EAP|0350|CTA ANGIO LOWER EXTREMITY|Medicare|MEDICARE ACUTE|3,430.25||||3,429.75||| 73718|EAP|0610|MRI LOWER EXT LT W/O CONT|United Healthcare|UNITED HEALTHCARE|||||58.50||| 73718|EAP|0610|MRI LOWER EXT LT W/O CONT|United Healthcare|UNITED HEALTHCARE OTHER|||||58.50||| 73718|EAP|0610|MRI LOWER EXT RT W/O CONT|Humana Medicare Advantage|HUMANA MA|||||58.50||| 73718|EAP|0610|MRI LOWER EXT LT W/O CONT|Humana Medicare Advantage|HUMANA MA|||||58.50||| 73718|EAP|0610|MRI LOWER EXT LT W/O CONT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|58.50||||||| 73718|EAP|0610|MRI LOWER EXT LT W/O CONT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||58.50||| 73718|EAP|0610|MRI LOWER EXT LT W/O CONT|Medicare|MEDICARE ACUTE|||||58.50||| 73720|EAP|0610|MRI LOWER LT.EXT.W&W/0 CO|Medicare|MEDICARE ACUTE|||||7,914.25||| 73720|EAP|0610|MRI LOWER LT.EXT.W&W/0 CO|Blue Cross PPO Specialty|BCBSTX PPO|||||7,914.25||| 73721|EAP|0610|MRI LOWER LT.EXT JOINT W/|Workers Compensation|UT EMPLOYEE INJURY|||||58.50||| 73721|EAP|0610|MRI LOWER RT.EXT JOINT W/|Workers Compensation|WORKERS COMPENSATION OTHER|||||58.50||| 73721|EAP|0610|MRI LOWER LT.EXT JOINT W/|United Healthcare|TML GROUP BENEFITS|||||58.50||| 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 LT.EXT JOINT W/|United Healthcare|UNITED HEALTHCARE OTHER|||||58.50||| 73721|EAP|0610|MRI LOWER RT.EXT JOINT W/|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||58.50||| 73721|EAP|0610|MRI LOWER LT.EXT JOINT W/|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||58.50||| 73721|EAP|0610|MRI LOWER LT.EXT JOINT W/|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||58.50||| 73721|EAP|0610|MRI LOWER RT.EXT JOINT W/|Blue Cross HMO Specialty|BCBSTX HMO|||||58.50||| 73721|EAP|0610|MRI LOWER LT.EXT JOINT W/|Access Direct Platinum|HEALTHFIRST TPA UMR|||||58.50||| 73721|EAP|0610|MRI LOWER RT.EXT JOINT W/|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||58.50||| 73721|EAP|0610|MRI LOWER RT.EXT JOINT W/|Aenta Medicare Advantage|AETNA MEDICARE MA|||||58.50||| 73721|EAP|0610|MRI LOWER RT.EXT JOINT W/|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||58.50||| 73721|EAP|0610|MRI LOWER RT.EXT JOINT W/|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||58.50||| 73721|EAP|0610|MRI LOWER LT.EXT JOINT W/|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||58.50||| 73721|EAP|0610|MRI LOWER LT.EXT JOINT W/|Humana Medicare Advantage|HUMANA MA|||||58.50||| 73721|EAP|0610|MRI LOWER RT.EXT JOINT W/|Humana Medicare Advantage|HUMANA MA|||||58.50||| 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 PPO Specialty|BCBSTX PPO|||||58.50||| 73721|EAP|0610|MRI LOWER RT.EXT JOINT W/|Blue Cross PPO Specialty|BCBSTX PPO|||||58.50||| 73721|EAP|0610|MRI LOWER RT.EXT JOINT W/|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||58.50||| 73721|EAP|0610|MRI LOWER RT.EXT JOINT W/|Managed Medicaid|MEDICAID AMERIGROUP|||||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 RT.EXT JOINT W/|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||58.50||| 73721|EAP|0610|MRI LOWER LT.EXT JOINT W/|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||58.50||| 73721|EAP|0610|MRI LOWER RT.EXT JOINT W/|Managed Medicaid|MEDICAID SUPERIOR|||||58.50||| 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 SUPERIOR|||||58.50||| 73721|EAP|0610|MRI LOWER LT.EXT JOINT W/|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||58.50||| 73721|EAP|0610|MRI LOWER LT.EXT JOINT W/|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||58.50||| 73721|EAP|0610|MRI LOWER RT.EXT JOINT W/|Tricare|TRICARE EAST REGION|||||58.50||| 73721|EAP|0610|MRI LOWER LT.EXT JOINT W/|Medicare|MEDICARE ACUTE|||||58.50||| 73721|EAP|0610|MRI LOWER RT.EXT JOINT W/|NON CONTRACTED|COMMERCIAL OTHER 1|||||58.50||| 73721|EAP|0610|MRI LOWER LT.EXT JOINT W/|NON CONTRACTED|COMMERCIAL OTHER 1|||||58.50||| 73721|EAP|0610|MRI LOWER LT.EXT JOINT W/|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||58.50||| 73721|EAP|0610|MRI LOWER RT.EXT JOINT W/|Medicare|MEDICARE ACUTE|||||58.50||| 73721|EAP|0610|MRI LOWER LT.EXT JOINT W/|Medicaid|MEDICAID|||||58.50||| 738|DRG||UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY W/O CC/MCC|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|20,627.05|6188.11|6188.11|6188.11|||| 74018|EAP|0320|KUB|Blue Cross PPO Specialty|BCBSTX PPO|452.25||||452.25||| 74018|EAP|0320|KUB|Cigna|CIGNA|||||452.25||| 74018|EAP|0320|KUB|Humana Medicare Advantage|HUMANA MA|452.25||||452.25||| 74018|EAP|0320|KUB|Blue Cross HMO Specialty|BCBSTX HMO|||||452.25||| 74018|EAP|0320|KUB|Access Direct Platinum|HEALTHFIRST TPA UMR|||||452.25||| 74018|EAP|0320|KUB|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||452.25||| 74018|EAP|0320|KUB|Aetna|AETNA PPO|||||452.25||| 74018|EAP|0320|KUB|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|452.25||||452.25||| 74018|EAP|0320|KUB|United Medicare Advantage|AARP UHC WEST COMPLETE MA|452.25||||452.25||| 74018|EAP|0320|KUB|Veterans Affairs|VETERANS ADMINISTRATION|452.25||||||| 74018|EAP|0320|KUB|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|452.25||||452.25||| 74018|EAP|0320|KUB|Workers Compensation|WORKERS COMPENSATION OTHER|||||452.25||| 74018|EAP|0320|KUB|United Medicare Advantage|UHC MEDICARE GOLD MA|||||452.25||| 74018|EAP|0320|KUB|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||452.25||| 74018|EAP|0320|KUB|United Healthcare|UNITED HEALTHCARE|||||452.25||| 74018|EAP|0320|KUB|United Healthcare|UNITED HEALTHCARE OTHER|452.25||||||| 74018|EAP|0320|KUB|Managed Medicaid|MEDICAID UNITED HEALTHCARE|452.25||||452.25||| 74018|EAP|0320|KUB|Aenta Medicare Advantage|AETNA MEDICARE MA|452.25||||||| 74018|EAP|0320|KUB|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||452.25||| 74018|EAP|0320|KUB|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|452.25||||452.25||| 74018|EAP|0320|KUB|Managed Medicare|HEALTHSPRING MA|452.25||||||| 74018|EAP|0320|KUB|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||452.25||| 74018|EAP|0320|KUB|Managed Medicaid|MEDICAID AMERIGROUP|452.25||||452.25||| 74018|EAP|0320|KUB|Managed Medicaid|MEDICAID SUPERIOR|452.25||||452.25||| 74018|EAP|0320|KUB|Medicaid|MEDICAID HMO|||||452.25||| 74018|EAP|0320|KUB|Tricare|TRICARE EAST REGION|||||452.25||| 74018|EAP|0320|KUB|Medicare|MEDICARE ACUTE|452.25||||452.25||| 74018|EAP|0320|KUB|Medicaid|MEDICAID TEXAS CHILDRENS|||||452.25||| 74018|EAP|0320|KUB|Medicaid|MEDICAID|452.25||||452.25||| 74018|EAP|0320|KUB|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||452.25||| 74018|EAP|0320|KUB|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||452.25||| 74018|EAP|0320|KUB|Rusk State Hospital|RUSK STATE HOSP|452.25||||||| 74018|EAP|0320|KUB|NON CONTRACTED|COMMERCIAL OTHER 1|||||452.25||| 74019|EAP|0320|ABDOMEN 2 VIEWS|Medicaid|MEDICAID HMO|||||515.75||| 74019|EAP|0320|ABDOMEN 2 VIEWS|Tricare|TRICARE EAST REGION|||||515.75||| 74019|EAP|0320|ABDOMEN 2 VIEWS|NON CONTRACTED|COMMERCIAL OTHER 1|||||515.75||| 74019|EAP|0320|ABDOMEN 2 VIEWS|Medicare|MEDICARE ACUTE|515.75||||515.75||| 74019|EAP|0320|ABDOMEN 2 VIEWS|Rusk State Hospital|RUSK STATE HOSP|515.75||||||| 74019|EAP|0320|ABDOMEN 2 VIEWS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||515.75||| 74019|EAP|0320|ABDOMEN 2 VIEWS|Managed Medicaid|MEDICAID AMERIGROUP|||||515.75||| 74019|EAP|0320|ABDOMEN 2 VIEWS|Managed Medicaid|MEDICAID SUPERIOR|||||515.75||| 74019|EAP|0320|ABDOMEN 2 VIEWS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|515.75||||515.75||| 74019|EAP|0320|ABDOMEN 2 VIEWS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||515.75||| 74019|EAP|0320|ABDOMEN 2 VIEWS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||515.75||| 74019|EAP|0320|ABDOMEN 2 VIEWS|Veterans Affairs|VETERANS ADMINISTRATION|515.75||||||| 74019|EAP|0320|ABDOMEN 2 VIEWS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|515.75||||515.75||| 74019|EAP|0320|X-RAY EXAM ABDOMEN 2 VIEW|Medicare|MEDICARE ACUTE|515.75||||515.75||| 74019|EAP|0320|ABDOMEN 2 VIEWS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||515.75||| 74019|EAP|0320|X-RAY EXAM ABDOMEN 2 VIEW|Blue Cross HMO Specialty|BCBSTX HMO|||||515.75||| 74019|EAP|0320|ABDOMEN 2 VIEWS|Blue Cross HMO Specialty|BCBSTX HMO|||||515.75||| 74019|EAP|0320|ABDOMEN 2 VIEWS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||515.75||| 74019|EAP|0320|ABDOMEN 2 VIEWS|Aenta Medicare Advantage|AETNA MEDICARE MA|515.75||||515.75||| 74019|EAP|0320|ABDOMEN 2 VIEWS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||515.75||| 74019|EAP|0320|ABDOMEN 2 VIEWS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|515.75||||||| 74019|EAP|0320|X-RAY EXAM ABDOMEN 2 VIEW|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||515.75||| 74019|EAP|0320|X-RAY EXAM ABDOMEN 2 VIEW|Humana Medicare Advantage|HUMANA MA|||||515.75||| 74019|EAP|0320|ABDOMEN 2 VIEWS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||515.75||| 74019|EAP|0320|ABDOMEN 2 VIEWS|Humana Medicare Advantage|HUMANA MA|||||515.75||| 74019|EAP|0320|ABDOMEN 2 VIEWS|Blue Cross PPO Specialty|BCBSTX PPO|||||515.75||| 74019|EAP|0320|X-RAY EXAM ABDOMEN 2 VIEW|Blue Cross PPO Specialty|BCBSTX PPO|||||515.75||| 74022|EAP|0320|ABD ACUTE SERIES|Blue Cross PPO Specialty|BCBSTX PPO|||||853.50||| 74022|EAP|0320|ABD ACUTE SERIES|Cigna|CIGNA|||||853.50||| 74022|EAP|0320|ABD ACUTE SERIES|Humana Medicare Advantage|HUMANA MA|853.50||||853.50||| 74022|EAP|0320|ABD ACUTE SERIES|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||853.50||| 74022|EAP|0320|ABD ACUTE SERIES|Aenta Medicare Advantage|AETNA MEDICARE MA|||||853.50||| 74022|EAP|0320|ABD ACUTE SERIES|Blue Cross HMO Specialty|BCBSTX HMO|||||853.50||| 74022|EAP|0320|ABD ACUTE SERIES|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||853.50||| 74022|EAP|0320|ABD ACUTE SERIES|United Healthcare|UNITED HEALTHCARE|||||853.50||| 74022|EAP|0320|ABD ACUTE SERIES|United Medicare Advantage|UHC MEDICARE GOLD MA|||||853.50||| 74022|EAP|0320|ABD ACUTE SERIES|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|853.50||||853.50||| 74022|EAP|0320|ABD ACUTE SERIES|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||853.50||| 74022|EAP|0320|ABD ACUTE SERIES|Veterans Affairs|VETERANS ADMINISTRATION|853.50||||||| 74022|EAP|0320|ABD ACUTE SERIES|United Healthcare|UNITED HEALTHCARE|853.50||||||| 74022|EAP|0320|ABD ACUTE SERIES|Managed Medicare|HEALTHSPRING MA|||||853.50||| 74022|EAP|0320|ABD ACUTE SERIES|Managed Medicaid|MEDICAID AMERIGROUP|||||853.50||| 74022|EAP|0320|ABD ACUTE SERIES|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|853.50||||853.50||| 74022|EAP|0320|ABD ACUTE SERIES|Managed Medicaid|MEDICAID SUPERIOR|||||853.50||| 74022|EAP|0320|ABD ACUTE SERIES|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||853.50||| 74022|EAP|0320|ABD ACUTE SERIES|Medicare|MEDICARE ACUTE|853.50||||853.50||| 74022|EAP|0320|ABD ACUTE SERIES|Medicaid|MEDICAID|||||853.50||| 74022|EAP|0320|ABD ACUTE SERIES|Medicaid|MEDICAID HMO|||||853.50||| 74022|EAP|0320|ABD ACUTE SERIES|NON CONTRACTED|COMMERCIAL OTHER 1|||||853.50||| 74022|EAP|0320|ABD ACUTE SERIES|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||853.50||| 741|DRG||UTERINE, ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W/O CC/MCC|Medicaid|MEDICAID|21,932.80|9599.49|9599.49|9599.49|||| 74150|EAP|0350|ABDOMEN W/O CONTRAST|United Healthcare|UNITED HEALTHCARE OTHER|||||3,627.75||| 74150|EAP|0350|ABDOMEN W/O CONTRAST|Humana Medicare Advantage|HUMANA MA|||||3,627.75||| 74150|EAP|0350|ABDOMEN W/O CONTRAST|Medicare|MEDICARE ACUTE|||||3,627.75||| 74160|EAP|0350|ABDOMEN W/CONTRAST|Managed Medicaid|MEDICAID SUPERIOR|||||4,738.75||| 74160|EAP|0350|ABDOMEN W/CONTRAST|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||4,738.75||| 74160|EAP|0350|ABDOMEN W/CONTRAST|Medicare|MEDICARE ACUTE|||||4,738.75||| 74160|EAP|0350|ABDOMEN W/CONTRAST|NON CONTRACTED|COMMERCIAL OTHER 1|4,738.75||||4,738.75||| 74160|EAP|0350|ABDOMEN W/CONTRAST|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||4,738.75||| 74160|EAP|0350|ABDOMEN W/CONTRAST|Blue Cross HMO Specialty|BCBSTX HMO|||||4,738.75||| 74160|EAP|0350|ABDOMEN W/CONTRAST|Blue Cross PPO Specialty|BCBSTX PPO|||||4,738.75||| 74160|EAP|0350|ABDOMEN W/CONTRAST|Humana Medicare Advantage|HUMANA MA|||||4,738.75||| 74160|EAP|0350|ABDOMEN W/CONTRAST|United Healthcare|UNITED HEALTHCARE OTHER|||||4,738.75||| 74160|EAP|0350|ABDOMEN W/CONTRAST|United Healthcare|UNITED HEALTHCARE|||||4,738.75||| 74170|EAP|0350|ABDOMEN W&W/O CONTRAST 24|United Medicare Advantage|UHC MEDICARE GOLD MA|||||53.74||| 74170|EAP|0350|ABDOMEN W&W/O CONTRAST 24|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|53.74||||||| 74170|EAP|0350|ABDOMEN W&W/O CONTRAST 24|Humana Medicare Advantage|HUMANA MA|||||53.74||| 74170|EAP|0350|ABDOMEN W&W/O CONTRAST 24|Blue Cross PPO Specialty|BCBSTX PPO|||||53.74||| 74170|EAP|0350|ABDOMEN W&W/O CONTRAST 24|Cigna|CIGNA|||||53.74||| 74170|EAP|0350|ABDOMEN W&W/O CONTRAST 24|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||53.74||| 74170|EAP|0350|ABDOMEN W&W/O CONTRAST 24|Medicare|MEDICARE ACUTE|||||53.74||| 74170|EAP|0350|ABDOMEN W&W/O CONTRAST 24|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||53.74||| 74174|EAP|0350|CTA ABD & PELVIS W/CONTRA|Managed Medicaid|MEDICAID SUPERIOR|57.00||||||| 74174|EAP|0350|CTA ABD & PELVIS W/CONTRA|Medicare|MEDICARE ACUTE|||||57.00||| 74174|EAP|0350|CTA ABD & PELVIS W/CONTRA|Blue Cross PPO Specialty|BCBSTX PPO|||||57.00||| 74174|EAP|0350|CTA ABD & PELVIS W/CONTRA|Humana Medicare Advantage|HUMANA MA|||||57.00||| 74174|EAP|0350|CTA ABD & PELVIS W/CONTRA|United Medicare Advantage|UHC MEDICARE GOLD MA|||||57.00||| 74175|EAP|0350|CT ANGIO ABDOMEN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3,573.50||| 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|Humana Medicare Advantage|HUMANA MA|||||3,573.50||| 74175|EAP|0350|CT ANGIO ABDOMEN|Medicare|MEDICARE ACUTE|||||3,573.50||| 74175|EAP|0350|CT ANGIO ABDOMEN|UTMB|UTMB CORRECTIONAL MANAGED CARE|3,573.50||||3,573.50||| 74175|EAP|0350|CT ANGIO ABDOMEN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||3,573.50||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|54.41||||54.41||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|Managed Medicaid|MEDICAID AMERIGROUP|||||54.41||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|Managed Medicaid|MEDICAID SUPERIOR|54.41||||54.41||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|Managed Medicare|HEALTHSPRING MA|||||54.41||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|Managed Medicaid|MEDICAID UNITED HEALTHCARE|54.41||||54.41||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|Medicaid|SUPERIOR HEALTHPLAN CHIP|54.41||||||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|Medicare|MEDICARE ACUTE|54.41||||54.41||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|UTMB|UTMB CORRECTIONAL MANAGED CARE|54.41||||54.41||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|Medicaid|MEDICAID|54.41||||54.41||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|Rusk State Hospital|RUSK STATE HOSP|||||54.41||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|NON CONTRACTED|COMMERCIAL OTHER 1|||||54.41||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|Veterans Affairs|VETERANS ADMINISTRATION|54.41||||54.41||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|United Medicare Advantage|UHC MEDICARE GOLD MA|54.41||||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|Tricare|TRICARE EAST REGION|||||54.41||| 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 Healthcare|UNITED HEALTHCARE|||||54.41||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|United Medicare Advantage|AARP UHC WEST COMPLETE MA|54.41||||54.41||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|54.41||||54.41||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||54.41||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|54.41||||54.41||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|Blue Cross PPO Specialty|BCBSTX PPO|||||54.41||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|Humana Medicare Advantage|HUMANA MA|54.41||||54.41||| 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|Cigna|CIGNA|||||54.41||| 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|Cigna|CIGNA|54.41||||||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|54.41||||54.41||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|Aenta Medicare Advantage|AETNA MEDICARE MA|54.41||||54.41||| 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|Aetna|AETNA PPO|||||54.41||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|Blue Cross HMO Specialty|BCBSTX HMO|||||54.41||| 74176|EAP|0350|CT ABDOMEN & PELVIS W/O C|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||54.41||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|7,108.75||||7,108.75||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Aenta Medicare Advantage|AETNA MEDICARE MA|||||7,108.75||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7,108.75||||7,108.75||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Blue Cross HMO Specialty|BCBSTX HMO|7,108.75||||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|Aetna|AETNA PPO|7,108.75||||7,108.75||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Blue Cross PPO Specialty|BCBSTX PPO|7,108.75||||7,108.75||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||7,108.75||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Humana Medicare Advantage|HUMANA MA|7,108.75||||7,108.75||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Cigna|CIGNA|7,108.75||||7,108.75||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Cigna|CIGNA|||||7,108.75||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|United Medicare Advantage|AARP UHC WEST COMPLETE MA|7,108.75||||7,108.75||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Workers Compensation|WORKERS COMPENSATION OTHER|||||7,108.75||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Blue Cross PPO Specialty|BCBSTX OTHER|||||7,108.75||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7,108.75||||7,108.75||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Veterans Affairs|VETERANS ADMINISTRATION|7,108.75||||7,108.75||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|United Healthcare|UNITED HEALTHCARE|7,108.75||||7,108.75||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|United Medicare Advantage|UHC MEDICARE GOLD MA|7,108.75||||7,108.75||| 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|UMR UNITED MEDICAL RESOURCES|7,108.75||||7,108.75||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Aetna|AETNA OTHER|||||7,108.75||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|NON CONTRACTED|COMMERCIAL OTHER 1|7,108.75||||7,108.75||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Medicaid|SUPERIOR HEALTHPLAN CHIP|7,108.75||||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|Tricare|TRICARE EAST REGION|||||7,108.75||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Medicare|MEDICARE ACUTE|7,108.75||||7,108.75||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|UTMB|UTMB CORRECTIONAL MANAGED CARE|7,108.75||||7,108.75||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Rusk State Hospital|RUSK STATE HOSP|7,108.75||||7,108.75||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Medicaid|MEDICAID|7,108.75||||7,108.75||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Managed Medicaid|MEDICAID SUPERIOR|7,108.75||||7,108.75||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7,108.75||||7,108.75||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7,108.75||||7,108.75||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Managed Medicaid|MEDICAID AMERIGROUP|7,108.75||||7,108.75||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||7,108.75||| 74177|EAP|0350|CT ABDOMEN & PELVIS W/CON|Managed Medicare|HEALTHSPRING MA|7,108.75||||7,108.75||| 74178|EAP|0350|CT ABDOMEN & PELVIS W/WO|Managed Medicaid|MEDICAID SUPERIOR|||||80.61||| 74178|EAP|0350|CT ABDOMEN & PELVIS W/WO|Medicare|MEDICARE ACUTE|||||80.61||| 74178|EAP|0350|CT ABDOMEN & PELVIS W/WO|NON CONTRACTED|COMMERCIAL OTHER 1|||||80.61||| 74178|EAP|0350|CT ABDOMEN & PELVIS W/WO|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||80.61||| 74178|EAP|0350|CT ABDOMEN & PELVIS W/WO|United Medicare Advantage|UHC MEDICARE GOLD MA|||||80.61||| 74178|EAP|0350|CT ABDOMEN & PELVIS W/WO|Humana Medicare Advantage|HUMANA MA|||||80.61||| 74178|EAP|0350|CT ABDOMEN & PELVIS W/WO|Cigna|CIGNA|||||80.61||| 74178|EAP|0350|CT ABDOMEN & PELVIS W/WO|Blue Cross PPO Specialty|BCBSTX PPO|||||80.61||| 74178|EAP|0350|CT ABDOMEN & PELVIS W/WO|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||80.61||| 74178|EAP|0350|CT ABDOMEN & PELVIS W/WO|Blue Cross HMO Specialty|BCBSTX HMO|||||80.61||| 74181|EAP|0610|MRI ABDOMEN W/O CONTRAST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||58.50||| 74181|EAP|0610|MRI ABDOMEN W/O CONTRAST|Blue Cross PPO Specialty|BCBSTX PPO|||||58.50||| 74181|EAP|0610|MRI ABDOMEN W/O CONTRAST|United Medicare Advantage|UHC MEDICARE GOLD MA|||||58.50||| 74181|EAP|0610|MRI MRCP BILIARY TREE|Medicare|MEDICARE ACUTE|||||58.50||| 74181|EAP|0610|MRI ABDOMEN W/O CONTRAST|Medicare|MEDICARE ACUTE|||||58.50||| 74181|EAP|0610|MRI ABDOMEN W/O CONTRAST|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||58.50||| 74181|EAP|0610|MRI MRCP BILIARY TREE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|58.50||||||| 74183|EAP|0614|MRI ABDOMEN W/WO CONTRAST|Medicare|MEDICARE ACUTE|7,914.25||||7,914.25||| 74183|EAP|0614|MRI ABDOMEN W/WO CONTRAST|NON CONTRACTED|COMMERCIAL OTHER 1|||||7,914.25||| 74183|EAP|0614|MRI ABDOMEN W/WO CONTRAST|United Healthcare|UNITED HEALTHCARE|||||7,914.25||| 74183|EAP|0614|MRI ABDOMEN W/WO CONTRAST|United Medicare Advantage|UHC MEDICARE GOLD MA|||||7,914.25||| 74183|EAP|0614|MRI ABDOMEN W/WO CONTRAST|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||7,914.25||| 74183|EAP|0614|MRI ABDOMEN W/WO CONTRAST|Humana Medicare Advantage|HUMANA MA|||||7,914.25||| 74183|EAP|0614|MRI ABDOMEN W/WO CONTRAST|Cigna|CIGNA|||||7,914.25||| 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|Blue Cross HMO Specialty|BCBSTX HMO|||||7,914.25||| 74183|EAP|0614|MRI ABDOMEN W/WO CONTRAST|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||7,914.25||| 74183|EAP|0614|MRI ABDOMEN W/WO CONTRAST|Access Direct Platinum|HEALTHFIRST TPA UMR|||||7,914.25||| 74183|EAP|0614|MRI ABDOMEN W/WO CONTRAST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||7,914.25||| 74185|EAP|0610|MRA ABDOMEN W/WO CONTRAST|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||7,914.25||| 742|DRG||UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W CC/MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|55,883.05|20307.58|20307.58|20307.58|||| 742|DRG||UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W CC/MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|22,741.55|20307.58|20307.58|20307.58|||| 74230|EAP|0320|MODIFIED BAS W/FLUORO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||849.25||| 74230|EAP|0320|MODIFIED BAS W/FLUORO|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||849.25||| 74230|EAP|0320|MODIFIED BAS W/FLUORO|Medicare|MEDICARE ACUTE|849.25||||849.25||| 74230|EAP|0320|MODIFIED BAS W/FLUORO|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||849.25||| 74230|EAP|0320|MODIFIED BAS W/FLUORO|United Medicare Advantage|UHC MEDICARE GOLD MA|||||849.25||| 74230|EAP|0320|MODIFIED BAS W/FLUORO|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||849.25||| 74230|EAP|0320|MODIFIED BAS W/FLUORO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||849.25||| 74230|EAP|0320|MODIFIED BAS W/FLUORO|Blue Cross PPO Specialty|BCBSTX PPO|||||849.25||| 74230|EAP|0320|MODIFIED BAS W/FLUORO|Humana Medicare Advantage|HUMANA MA|849.25||||849.25||| 74240|EAP|0320|UPPER GI SERIES|Humana Medicare Advantage|HUMANA MA|||||1,485.50||| 74240|EAP|0320|UPPER GI SERIES|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,485.50||| 74240|EAP|0320|UPPER GI SERIES|Medicare|MEDICARE ACUTE|||||1,485.50||| 74240|EAP|0320|UPPER GI SERIES|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1,485.50||| 74270|EAP|0320|BE SOLID|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||8.13||| 74270|EAP|0320|BE SOLID|Tricare|TRICARE EAST REGION|||||8.13||| 74270|EAP|0320|BE SOLID|Medicare|MEDICARE ACUTE|||||8.13||| 74270|EAP|0320|BE SOLID|United Medicare Advantage|UHC MEDICARE GOLD MA|||||8.13||| 74270|EAP|0320|BE SOLID|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||8.13||| 74270|EAP|0320|BE SOLID|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||8.13||| 74270|EAP|0320|BE SOLID|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||8.13||| 74270|EAP|0320|BE SOLID|Blue Cross PPO Specialty|BCBSTX PPO|||||8.13||| 74270|EAP|0320|BE SOLID|Humana Medicare Advantage|HUMANA MA|||||8.13||| 74280|EAP|0320|BE W AIR|Blue Cross HMO Specialty|BCBSTX HMO|||||952.50||| 743|DRG||UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W/O CC/MCC|NON CONTRACTED|COMMERCIAL OTHER 1|17,991.30|11474.66|15263.19|4242.63|||| 743|DRG||UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W/O CC/MCC|United Healthcare|UNITED HEALTHCARE OTHER|27,698.05|11474.66|15263.19|4242.63|||| 743|DRG||UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W/O CC/MCC|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|20,262.05|6078.61|15263.19|4242.63|||| 743|DRG||UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W/O CC/MCC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|20,809.30|4402.16|15263.19|4242.63|||| 743|DRG||UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W/O CC/MCC|Managed Medicaid|MEDICAID SUPERIOR|24,974.68|15263.19|15263.19|4242.63|||| 743|DRG||UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|22,217.55|4621.93|15263.19|4242.63|||| 743|DRG||UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|24,213.55|4242.63|15263.19|4242.63|||| 74300|EAP|0320|CHOLANGIOGRAM OPERATIVE|United Healthcare|UNITED HEALTHCARE|1,479.50||||||| 74300|EAP|0320|CHOLANGIOGRAM OPERATIVE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|1,479.50||||||| 74300|EAP|0320|CHOLANGIOGRAM OPERATIVE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,479.50||| 74300|EAP|0320|CHOLANGIOGRAM OPERATIVE|United Healthcare|UMR UNITED MEDICAL RESOURCES|1,479.50||||||| 74300|EAP|0320|CHOLANGIOGRAM OPERATIVE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,479.50||| 74300|EAP|0320|CHOLANGIOGRAM OPERATIVE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,479.50||| 74300|EAP|0320|CHOLANGIOGRAM OPERATIVE|Blue Cross HMO Specialty|BCBSTX HMO|1,479.50||||1,479.50||| 74300|EAP|0320|CHOLANGIOGRAM OPERATIVE|Blue Cross PPO Specialty|BCBSTX PPO|||||1,479.50||| 74300|EAP|0320|CHOLANGIOGRAM OPERATIVE|Humana Medicare Advantage|HUMANA MA|1,479.50||||||| 74300|EAP|0320|CHOLANGIOGRAM OPERATIVE|Managed Medicaid|MEDICAID SUPERIOR|||||1,479.50||| 74300|EAP|0320|CHOLANGIOGRAM OPERATIVE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,479.50||| 74300|EAP|0320|CHOLANGIOGRAM OPERATIVE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1,479.50||| 74300|EAP|0320|CHOLANGIOGRAM OPERATIVE|Medicare|MEDICARE ACUTE|1,479.50||||1,479.50||| 744|DRG||D&C, CONIZATION, LAPAROSCOPY & TUBAL INTERRUPTION W CC/MCC|Managed Medicaid|MEDICAID SUPERIOR|64,268.55|13940.15|13940.15|13940.15|||| 74455|EAP|0320|CYSTOGRAM VOIDING|Managed Medicaid|MEDICAID AMERIGROUP|1,388.25||||||| 74740|EAP|0320|HYSTEROSALPINGOGRAM|Managed Medicaid|MEDICAID SUPERIOR|||||21.84||| 748|DRG||FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES|United Medicare Advantage|UHC MEDICARE GOLD MA|11,427.55|11427.55|11427.55|11427.55|||| 75571|EAP|0350|CT CALCIUM SCORING|Medicare|MEDICARE ACUTE|||||0.75||| 75571|EAP|0350|CT CALCIUM SCORING|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.75||| 75571|EAP|0350|CT CALCIUM SCORING|Managed Medicare|HEALTHSPRING MA|||||0.75||| 75571|EAP|0350|CT CALCIUM SCORING|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.75||| 75571|EAP|0350|CT CALCIUM SCORING|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.75||| 75571|EAP|0350|CT CALCIUM SCORING|Aetna|AETNA PPO|||||0.75||| 75571|EAP|0350|CT CALCIUM SCORING|Blue Cross HMO Specialty|BCBSTX HMO|||||0.75||| 75571|EAP|0350|CT CALCIUM SCORING|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||0.75||| 75571|EAP|0350|CT CALCIUM SCORING|Cigna|CIGNA|||||0.75||| 75571|EAP|0350|CT CALCIUM SCORING|Humana Medicare Advantage|HUMANA MA|||||0.75||| 75571|EAP|0350|CT CALCIUM SCORING|Blue Cross PPO Specialty|BCBSTX PPO|||||0.75||| 75571|EAP|0350|CT CALCIUM SCORING|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.75||| 75571|EAP|0350|CT CALCIUM SCORING|United Healthcare|UNITED HEALTHCARE OTHER|||||0.75||| 75571|EAP|0350|CT CALCIUM SCORING|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||0.75||| 75571|EAP|0350|CT CALCIUM SCORING|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.75||| 75635|EAP|0350|CT ANGIO AORTA/ILIOFEM RU|United Medicare Advantage|UHC MEDICARE GOLD MA|||||4,103.75||| 75635|EAP|0350|CT ANGIO AORTA/ILIOFEM RU|Humana Medicare Advantage|HUMANA MA|4,103.75||||4,103.75||| 75635|EAP|0350|CT ANGIO AORTA/ILIOFEM RU|Blue Cross PPO Specialty|BCBSTX PPO|||||4,103.75||| 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|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4,103.75||||||| 75635|EAP|0350|CT ANGIO AORTA/ILIOFEM RU|Medicare|MEDICARE ACUTE|||||4,103.75||| 76000|EAP|0320|XR C-ARM/FLUORO 31-60 MIN|NON CONTRACTED|COMMERCIAL OTHER 1|759.25||||||| 76000|EAP|0320|XR C-ARM/FLUORO 0-30 MINU|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||517.75||| 76000|EAP|0320|XR C-ARM/FLUORO 0-30 MINU|Medicaid|MEDICAID|759.25||||517.75||| 76000|EAP|0320|XR C-ARM/FLUORO 31-60 MIN|Medicare|MEDICARE ACUTE|759.25||||759.25||| 76000|EAP|0320|XR C-ARM/FLUORO 0-30 MINU|Medicare|MEDICARE PART B ONLY IP|||||517.75||| 76000|EAP|0320|XR C-ARM/FLUORO 0-30 MINU|Medicare|MEDICARE ACUTE|759.25||||517.75||| 76000|EAP|0320|XR C-ARM/FLUORO 31-60 MIN|Medicaid|MEDICAID|759.25||||759.25||| 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 SUPERIOR|||||517.75||| 76000|EAP|0320|XR C-ARM/FLUORO 0-30 MINU|Managed Medicare|HEALTHSPRING MA|||||517.75||| 76000|EAP|0320|XR C-ARM/FLUORO 0-30 MINU|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||517.75||| 76000|EAP|0320|XR C-ARM/FLUORO 31-60 MIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||759.25||| 76000|EAP|0320|XR C-ARM/FLUORO 31-60 MIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|759.25||||759.25||| 76000|EAP|0320|XR C-ARM/FLUORO 31-60 MIN|Blue Cross HMO Specialty|BCBSTX HMO|||||759.25||| 76000|EAP|0320|XR C-ARM/FLUORO 31-60 MIN|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||759.25||| 76000|EAP|0320|XR C-ARM/FLUORO 31-60 MIN|Aenta Medicare Advantage|AETNA MEDICARE MA|759.25||||||| 76000|EAP|0320|XR C-ARM/FLUORO 31-60 MIN|Humana Medicare Advantage|HUMANA MA|759.25||||759.25||| 76000|EAP|0320|XR C-ARM/FLUORO 0-30 MINU|Blue Cross PPO Specialty|BCBSTX PPO|759.25||||517.75||| 76000|EAP|0320|XR C-ARM/FLUORO 0-30 MINU|Humana Medicare Advantage|HUMANA MA|759.25||||517.75||| 76000|EAP|0320|XR C-ARM/FLUORO 31-60 MIN|Blue Cross PPO Specialty|BCBSTX PPO|759.25||||759.25||| 76000|EAP|0320|XR C-ARM/FLUORO 0-30 MINU|United Healthcare|UNITED HEALTHCARE|||||517.75||| 76000|EAP|0320|XR C-ARM/FLUORO 0-30 MINU|United Healthcare|UNITED HEALTHCARE OTHER|||||517.75||| 76000|EAP|0320|XR C-ARM/FLUORO 31-60 MIN|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|759.25||||||| 76000|EAP|0320|XR C-ARM/FLUORO 31-60 MIN|United Medicare Advantage|UHC MEDICARE GOLD MA|759.25||||||| 76000|EAP|0320|XR C-ARM/FLUORO 0-30 MINU|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||517.75||| 76000|EAP|0320|XR C-ARM/FLUORO 31-60 MIN|United Healthcare|UNITED HEALTHCARE|||||759.25||| 76000|EAP|0320|XR C-ARM/FLUORO 31-60 MIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||759.25||| 76000|EAP|0320|XR C-ARM/FLUORO 31-60 MIN|United Medicare Advantage|AARP UHC WEST COMPLETE MA|759.25||||||| 76010|EAP|0320|FOREIGN BODY FILM NOSE TO|United Healthcare|UNITED HEALTHCARE|||||6.27||| 76010|EAP|0320|FOREIGN BODY FILM NOSE TO|Managed Medicaid|MEDICAID SUPERIOR|||||6.27||| 76499|EAP|0320|XR MRI CLEARANCE FOR META|Blue Cross PPO Specialty|BCBSTX PPO|||||618.75||| 76499|EAP|0320|XR MRI CLEARANCE FOR META|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||618.75||| 76499|EAP|0320|XR MRI CLEARANCE FOR META|Blue Cross HMO Specialty|BCBSTX HMO|||||618.75||| 76506|EAP|0921|ENCEPHALOGRAM|Medicaid|MEDICAID|||||7.55||| 76506|EAP|0921|ENCEPHALOGRAM|Managed Medicaid|MEDICAID SUPERIOR|7.55||||7.55||| 76506|EAP|0921|ENCEPHALOGRAM|Blue Cross PPO Specialty|BCBSTX PPO|7.55||||||| 76536|EAP|0400|THYROID ULTRASOUND|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,094.25||| 76536|EAP|0400|US SOFT TISSUE HEAD & NEC|United Medicare Advantage|UHC MEDICARE GOLD MA|||||292.50||| 76536|EAP|0400|THYROID ULTRASOUND|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,094.25||| 76536|EAP|0400|THYROID ULTRASOUND|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1,094.25||| 76536|EAP|0400|US SOFT TISSUE HEAD & NEC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||292.50||| 76536|EAP|0400|THYROID ULTRASOUND|United Healthcare|TML GROUP BENEFITS|||||1,094.25||| 76536|EAP|0400|THYROID ULTRASOUND|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,094.25||| 76536|EAP|0400|THYROID ULTRASOUND|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,094.25||| 76536|EAP|0400|US SOFT TISSUE HEAD & NEC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||292.50||| 76536|EAP|0400|THYROID ULTRASOUND|Blue Cross HMO Specialty|BCBSTX HMO|||||1,094.25||| 76536|EAP|0400|THYROID ULTRASOUND|Humana Medicare Advantage|HUMANA MA|||||1,094.25||| 76536|EAP|0400|US SOFT TISSUE HEAD & NEC|Cigna|CIGNA|||||292.50||| 76536|EAP|0400|US SOFT TISSUE HEAD & NEC|Blue Cross PPO Specialty|BCBSTX PPO|||||292.50||| 76536|EAP|0400|THYROID ULTRASOUND|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1,094.25||| 76536|EAP|0400|THYROID ULTRASOUND|Blue Cross PPO Specialty|BCBSTX OTHER|||||1,094.25||| 76536|EAP|0400|THYROID ULTRASOUND|Blue Cross PPO Specialty|BCBSTX PPO|||||1,094.25||| 76536|EAP|0400|US SOFT TISSUE HEAD & NEC|Humana Medicare Advantage|HUMANA MA|||||292.50||| 76536|EAP|0400|US SOFT TISSUE HEAD & NEC|Managed Medicaid|MEDICAID SUPERIOR|||||292.50||| 76536|EAP|0400|US SOFT TISSUE HEAD & NEC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||292.50||| 76536|EAP|0400|US SOFT TISSUE HEAD & NEC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||292.50||| 76536|EAP|0400|THYROID ULTRASOUND|Managed Medicaid|MEDICAID AMERIGROUP|||||1,094.25||| 76536|EAP|0400|US SOFT TISSUE HEAD & NEC|Managed Medicaid|MEDICAID AMERIGROUP|||||292.50||| 76536|EAP|0400|THYROID ULTRASOUND|Managed Medicare|HEALTHSPRING MA|||||1,094.25||| 76536|EAP|0400|THYROID ULTRASOUND|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1,094.25||| 76536|EAP|0400|THYROID ULTRASOUND|Managed Medicare|BCBS MEDICARE PPO MA|||||1,094.25||| 76536|EAP|0400|THYROID ULTRASOUND|United Healthcare|UNITED HEALTHCARE|||||1,094.25||| 76536|EAP|0400|THYROID ULTRASOUND|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,094.25||| 76536|EAP|0400|US SOFT TISSUE HEAD & NEC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||292.50||| 76536|EAP|0400|THYROID ULTRASOUND|Managed Medicaid|MEDICAID SUPERIOR|||||1,094.25||| 76536|EAP|0400|THYROID ULTRASOUND|Medicaid|MEDICAID|||||1,094.25||| 76536|EAP|0400|THYROID ULTRASOUND|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1,094.25||| 76536|EAP|0400|THYROID ULTRASOUND|UTMB|UTMB CORRECTIONAL MANAGED CARE|1,094.25||||||| 76536|EAP|0400|US SOFT TISSUE HEAD & NEC|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||292.50||| 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|||||292.50||| 76536|EAP|0400|THYROID ULTRASOUND|Medicare|MEDICARE ACUTE|||||1,094.25||| 76536|EAP|0400|US SOFT TISSUE HEAD & NEC|Medicare|MEDICARE ACUTE|||||292.50||| 76604|EAP|0400|US CHEST INCL MEDIOSTINUM|Medicare|MEDICARE ACUTE|||||598.50||| 76604|EAP|0400|US CHEST INCL MEDIOSTINUM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|598.50||||598.50||| 76604|EAP|0400|US CHEST INCL MEDIOSTINUM|Managed Medicaid|MEDICAID AMERIGROUP|||||598.50||| 76604|EAP|0400|US CHEST INCL MEDIOSTINUM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||598.50||| 76604|EAP|0400|US CHEST INCL MEDIOSTINUM|Blue Cross PPO Specialty|BCBSTX OTHER|598.50||||598.50||| 76604|EAP|0400|US CHEST INCL MEDIOSTINUM|Blue Cross HMO Specialty|BCBSTX HMO|||||598.50||| 76604|EAP|0400|US CHEST INCL MEDIOSTINUM|United Healthcare|TML GROUP BENEFITS|||||598.50||| 76604|EAP|0400|US CHEST INCL MEDIOSTINUM|United Medicare Advantage|UHC MEDICARE GOLD MA|598.50||||||| 76604|EAP|0400|US CHEST INCL MEDIOSTINUM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|598.50||||||| 76641|EAP|0401|BREAST BILAT US|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||6.23||| 76641|EAP|0401|BREAST BILAT US|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||6.23||| 76641|EAP|0401|BREAST BILAT US|United Medicare Advantage|UHC MEDICARE GOLD MA|||||6.23||| 76641|EAP|0401|BREAST BILAT US|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||6.23||| 76641|EAP|0401|BREAST BILAT US|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||6.23||| 76641|EAP|0401|BREAST BILAT US|Blue Cross HMO Specialty|BCBSTX HMO|||||6.23||| 76641|EAP|0401|BREAST BILAT US|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6.23||| 76641|EAP|0401|BREAST BILAT US|Blue Cross PPO Specialty|BCBSTX PPO|||||6.23||| 76641|EAP|0401|BREAST BILAT US|Humana Medicare Advantage|HUMANA MA|||||6.23||| 76641|EAP|0401|BREAST BILAT US|Managed Medicaid|MEDICAID SUPERIOR|||||6.23||| 76641|EAP|0401|BREAST BILAT US|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||6.23||| 76641|EAP|0401|BREAST BILAT US|Managed Medicaid|MEDICAID AMERIGROUP|||||6.23||| 76641|EAP|0401|BREAST BILAT US|Managed Medicare|BCBS MEDICARE PPO MA|||||6.23||| 76641|EAP|0401|BREAST BILAT US|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||6.23||| 76641|EAP|0401|BREAST BILAT US|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||6.23||| 76641|EAP|0401|BREAST BILAT US|NON CONTRACTED|COMMERCIAL OTHER 1|||||6.23||| 76641|EAP|0401|BREAST BILAT US|Medicare|MEDICARE ACUTE|||||6.23||| 76642|EAP|0401|BREAST US RT.|Medicare|MEDICARE ACUTE|||||583.25||| 76642|EAP|0402|BREAST US LT.|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||583.25||| 76642|EAP|0402|BREAST US LT.|NON CONTRACTED|COMMERCIAL OTHER 1|||||583.25||| 76642|EAP|0402|BREAST US LT.|Medicare|MEDICARE ACUTE|||||583.25||| 76642|EAP|0401|BREAST US RT.|NON CONTRACTED|COMMERCIAL OTHER 1|||||583.25||| 76642|EAP|0402|BREAST US LT.|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||583.25||| 76642|EAP|0402|BREAST US LT.|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||583.25||| 76642|EAP|0401|BREAST US RT.|Managed Medicaid|MEDICAID SUPERIOR|||||583.25||| 76642|EAP|0402|BREAST US LT.|Managed Medicaid|MEDICAID SUPERIOR|||||583.25||| 76642|EAP|0401|BREAST US RT.|Managed Medicare|HEALTHSPRING MA|||||583.25||| 76642|EAP|0401|BREAST US RT.|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||583.25||| 76642|EAP|0402|BREAST US LT.|Managed Medicaid|MEDICAID AMERIGROUP|||||583.25||| 76642|EAP|0401|BREAST US RT.|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||583.25||| 76642|EAP|0402|BREAST US LT.|Cigna|CIGNA|||||583.25||| 76642|EAP|0401|BREAST US RT.|Humana Medicare Advantage|HUMANA MA|||||583.25||| 76642|EAP|0402|BREAST US LT.|Humana Medicare Advantage|HUMANA MA|||||583.25||| 76642|EAP|0401|BREAST US RT.|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||583.25||| 76642|EAP|0401|BREAST US RT.|Managed Medicaid|MEDICAID AMERIGROUP|||||583.25||| 76642|EAP|0401|BREAST US RT.|Cigna|CIGNA|||||583.25||| 76642|EAP|0401|BREAST US RT.|Blue Cross PPO Specialty|BCBSTX PPO|||||583.25||| 76642|EAP|0402|BREAST US LT.|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||583.25||| 76642|EAP|0402|BREAST US LT.|Blue Cross PPO Specialty|BCBSTX PPO|||||583.25||| 76642|EAP|0401|BREAST US RT.|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||583.25||| 76642|EAP|0402|BREAST US LT.|Aenta Medicare Advantage|AETNA MEDICARE MA|||||583.25||| 76642|EAP|0401|BREAST US RT.|Blue Cross HMO Specialty|BCBSTX HMO|||||583.25||| 76642|EAP|0402|BREAST US LT.|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||583.25||| 76642|EAP|0402|BREAST US LT.|Tricare|TRICARE EAST REGION|||||583.25||| 76642|EAP|0402|BREAST US LT.|Aetna|AETNA PPO|||||583.25||| 76642|EAP|0402|BREAST US LT.|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||583.25||| 76642|EAP|0401|BREAST US RT.|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||583.25||| 76642|EAP|0402|BREAST US LT.|Blue Cross HMO Specialty|BCBSTX HMO|||||583.25||| 76642|EAP|0402|BREAST US LT.|United Healthcare|UNITED HEALTHCARE OTHER|||||583.25||| 76642|EAP|0402|BREAST US LT.|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||583.25||| 76642|EAP|0401|BREAST US RT.|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||583.25||| 76642|EAP|0401|BREAST US RT.|United Healthcare|UNITED HEALTHCARE OTHER|||||583.25||| 76642|EAP|0401|BREAST US RT.|Veterans Affairs|VETERANS ADMINISTRATION|||||583.25||| 76642|EAP|0402|BREAST US LT.|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||583.25||| 76642|EAP|0401|BREAST US RT.|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||583.25||| 76642|EAP|0401|BREAST US RT.|United Medicare Advantage|UHC MEDICARE GOLD MA|||||583.25||| 76642|EAP|0402|BREAST US LT.|United Medicare Advantage|UHC MEDICARE GOLD MA|||||583.25||| 76642|EAP|0401|BREAST US RT.|United Healthcare|UNITED HEALTHCARE|||||583.25||| 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|United Healthcare|UNITED HEALTHCARE OTHER|||||1,860.75||| 76700|EAP|0402|ABDOMINAL ULTRASOUND|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,860.75||| 76700|EAP|0402|ABDOMINAL ULTRASOUND|United Healthcare|TML GROUP BENEFITS|||||1,860.75||| 76700|EAP|0400||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|13.16||||||| 76700|EAP|0402|ABDOMINAL ULTRASOUND|Blue Cross HMO Specialty|BCBSTX HMO|||||1,860.75||| 76700|EAP|0402|ABDOMINAL ULTRASOUND|Aetna|AETNA OTHER|||||1,860.75||| 76700|EAP|0402|ABDOMINAL ULTRASOUND|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,860.75||| 76700|EAP|0400||Blue Cross HMO Specialty|BCBSTX HMO|||||13.16||| 76700|EAP|0402|ABDOMINAL ULTRASOUND|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,860.75||| 76700|EAP|0402|ABDOMINAL ULTRASOUND|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,860.75||| 76700|EAP|0402|ABDOMINAL ULTRASOUND|Cigna|CIGNA|||||1,860.75||| 76700|EAP|0400||Blue Cross PPO Specialty|BCBSTX PPO|||||13.16||| 76700|EAP|0400||Humana Medicare Advantage|HUMANA MA|13.16||||13.16||| 76700|EAP|0402|ABDOMINAL ULTRASOUND|Blue Cross PPO Specialty|BCBSTX OTHER|||||1,860.75||| 76700|EAP|0400||United Medicare Advantage|UHC MEDICARE GOLD MA|||||13.16||| 76700|EAP|0402|ABDOMINAL ULTRASOUND|Blue Cross PPO Specialty|BCBSTX PPO|||||1,860.75||| 76700|EAP|0402|ABDOMINAL ULTRASOUND|Humana Medicare Advantage|HUMANA MA|||||1,860.75||| 76700|EAP|0400||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||13.16||| 76700|EAP|0402|ABDOMINAL ULTRASOUND|Managed Medicare|HEALTHSPRING MA|||||1,860.75||| 76700|EAP|0402|ABDOMINAL ULTRASOUND|United Healthcare|UNITED HEALTHCARE|1,860.75||||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|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,860.75||| 76700|EAP|0402|ABDOMINAL ULTRASOUND|Managed Medicaid|MEDICAID SUPERIOR|||||1,860.75||| 76700|EAP|0400||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||13.16||| 76700|EAP|0400||Managed Medicaid|MEDICAID SUPERIOR|||||13.16||| 76700|EAP|0400||Medicare|MEDICARE ACUTE|||||13.16||| 76700|EAP|0400||Medicaid|MEDICAID|13.16||||13.16||| 76700|EAP|0402|ABDOMINAL ULTRASOUND|NON CONTRACTED|COMMERCIAL OTHER 1|||||1,860.75||| 76700|EAP|0402|ABDOMINAL ULTRASOUND|Medicaid|MEDICAID|||||1,860.75||| 76700|EAP|0402|ABDOMINAL ULTRASOUND|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1,860.75||| 76700|EAP|0402|ABDOMINAL ULTRASOUND|Tricare|TRICARE EAST REGION|||||1,860.75||| 76700|EAP|0402|ABDOMINAL ULTRASOUND|Medicare|MEDICARE ACUTE|1,860.75||||1,860.75||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|NON CONTRACTED|COMMERCIAL OTHER 1|||||915.25||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|Tricare|TRICARE EAST REGION|||||915.25||| 76705|EAP|0402|GALLBLADDER ULTRASOUND|UTMB|UTMB CORRECTIONAL MANAGED CARE|1,395.75||||||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|Medicaid|MOLINA HEALTHCARE OF TEXAS|915.25||||915.25||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|Medicaid|SUPERIOR HEALTHPLAN CHIP|915.25||||915.25||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|Medicaid|MEDICAID|||||915.25||| 76705|EAP|0402|GALLBLADDER ULTRASOUND|Medicare|MEDICARE ACUTE|1,395.75||||1,395.75||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|Medicare|MEDICARE ACUTE|915.25||||915.25||| 76705|EAP|0402|GALLBLADDER ULTRASOUND|Rusk State Hospital|RUSK STATE HOSP|||||1,395.75||| 76705|EAP|0402|GALLBLADDER ULTRASOUND|Managed Medicaid|MEDICAID AMERIGROUP|||||1,395.75||| 76705|EAP|0400|US EXAM ABDOMEN LIMITED|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||13.16||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|Managed Medicaid|MEDICAID AMERIGROUP|||||915.25||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||915.25||| 76705|EAP|0400|US EXAM ABDOMEN LIMITED|Managed Medicaid|MEDICAID SUPERIOR|||||13.16||| 76705|EAP|0402|GALLBLADDER ULTRASOUND|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|915.25||||1,395.75||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|915.25||||915.25||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|Humana Medicare Advantage|HUMANA MA|915.25||||915.25||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|915.25||||||| 76705|EAP|0402|GALLBLADDER ULTRASOUND|Managed Medicaid|MEDICAID SUPERIOR|1,395.75||||1,395.75||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|Blue Cross PPO Specialty|BCBSTX OTHER|915.25||||||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|Blue Cross PPO Specialty|BCBSTX PPO|915.25||||915.25||| 76705|EAP|0402|GALLBLADDER ULTRASOUND|Humana Medicare Advantage|HUMANA MA|1,395.75||||1,395.75||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|Cigna|CIGNA|915.25||||||| 76705|EAP|0402|GALLBLADDER ULTRASOUND|Blue Cross PPO Specialty|BCBSTX PPO|1,395.75||||1,395.75||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|Blue Cross HMO Specialty|BCBSTX HMO|915.25||||915.25||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|Managed Medicaid|MEDICAID SUPERIOR|1,395.75||||915.25||| 76705|EAP|0402|GALLBLADDER ULTRASOUND|Blue Cross HMO Specialty|BCBSTX HMO|915.25||||1,395.75||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||915.25||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||915.25||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|Aenta Medicare Advantage|AETNA MEDICARE MA|915.25||||915.25||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|UTMB|UTMB CORRECTIONAL MANAGED CARE|915.25||||||| 76705|EAP|0402|GALLBLADDER ULTRASOUND|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,395.75||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||915.25||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|Aetna|AETNA OTHER|||||915.25||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|United Healthcare|UNITED HEALTHCARE|||||915.25||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|United Healthcare|UNITED HEALTHCARE OTHER|||||915.25||| 76705|EAP|0402|GALLBLADDER ULTRASOUND|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|915.25||||1,395.75||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|United Medicare Advantage|AARP UHC WEST COMPLETE MA|915.25||||||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|United Medicare Advantage|UHC MEDICARE GOLD MA|1,395.75||||915.25||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|United Healthcare|UNITED HEALTHCARE|915.25||||||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||915.25||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|United Healthcare|UMR UNITED MEDICAL RESOURCES|915.25||||||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|Veterans Affairs|VETERANS ADMINISTRATION|915.25||||||| 76705|EAP|0402|ABDOMINAL LIMITED ULTRASO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|915.25||||915.25||| 76705|EAP|0402|GALLBLADDER ULTRASOUND|Workers Compensation|WORKERS COMPENSATION OTHER|||||1,395.75||| 76706|EAP|0402|US AORTA SCREENING|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||612.25||| 76706|EAP|0402|US AORTA SCREENING|United Medicare Advantage|UHC MEDICARE GOLD MA|||||612.25||| 76706|EAP|0402|US AORTA SCREENING|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||612.25||| 76706|EAP|0402|US AORTA SCREENING|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||612.25||| 76706|EAP|0402|US AORTA SCREENING|Cigna|CIGNA|||||612.25||| 76706|EAP|0402|US AORTA SCREENING|Veterans Affairs|VETERANS ADMINISTRATION|||||612.25||| 76706|EAP|0402|US AORTA SCREENING|Blue Cross PPO Specialty|BCBSTX PPO|||||612.25||| 76706|EAP|0402|US AORTA SCREENING|Humana Medicare Advantage|HUMANA MA|||||612.25||| 76706|EAP|0402|US AORTA SCREENING|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||612.25||| 76706|EAP|0402|US AORTA SCREENING|Managed Medicare|HEALTHSPRING MA|||||612.25||| 76706|EAP|0402|US AORTA SCREENING|Managed Medicaid|MEDICAID SUPERIOR|||||612.25||| 76706|EAP|0402|US AORTA SCREENING|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||612.25||| 76706|EAP|0402|US AORTA SCREENING|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||612.25||| 76706|EAP|0402|US AORTA SCREENING|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||612.25||| 76706|EAP|0402|US AORTA SCREENING|Tricare|TRICARE EAST REGION|||||612.25||| 76706|EAP|0402|US AORTA SCREENING|NON CONTRACTED|COMMERCIAL OTHER 1|||||612.25||| 76706|EAP|0402|US AORTA SCREENING|Medicare|MEDICARE ACUTE|||||612.25||| 76775|EAP|0400|RENAL ULTRASOUND|Medicare|MEDICARE ACUTE|1,435.50||||1,435.50||| 76775|EAP|0400|RENAL ULTRASOUND|NON CONTRACTED|COMMERCIAL OTHER 1|||||1,435.50||| 76775|EAP|0400|RENAL ULTRASOUND|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||1,435.50||| 76775|EAP|0400|RENAL ULTRASOUND|Medicaid|SUPERIOR HEALTHPLAN CHIP|1,435.50||||1,435.50||| 76775|EAP|0400|RENAL ULTRASOUND|Medicaid|MEDICAID|1,435.50||||1,435.50||| 76775|EAP|0400|RENAL ULTRASOUND|UTMB|UTMB CORRECTIONAL MANAGED CARE|1,435.50||||||| 76775|EAP|0400|RENAL ULTRASOUND|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,435.50||||1,435.50||| 76775|EAP|0400|RENAL ULTRASOUND|Managed Medicare|HEALTHSPRING MA|||||1,435.50||| 76775|EAP|0400|RENAL ULTRASOUND|Managed Medicaid|MEDICAID SUPERIOR|1,435.50||||1,435.50||| 76775|EAP|0400|RENAL ULTRASOUND|Medicaid|MEDICAID HMO|||||1,435.50||| 76775|EAP|0400|RENAL ULTRASOUND|Managed Medicaid|MEDICAID AMERIGROUP|||||1,435.50||| 76775|EAP|0400|RENAL ULTRASOUND|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,435.50||||1,435.50||| 76775|EAP|0400|RENAL ULTRASOUND|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1,435.50||||1,435.50||| 76775|EAP|0400|RENAL ULTRASOUND|Cigna|CIGNA|||||1,435.50||| 76775|EAP|0400|RENAL ULTRASOUND|Humana Medicare Advantage|HUMANA MA|1,435.50||||1,435.50||| 76775|EAP|0400|RENAL ULTRASOUND|Blue Cross PPO Specialty|BCBSTX PPO|1,435.50||||1,435.50||| 76775|EAP|0400|RENAL ULTRASOUND|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,435.50||| 76775|EAP|0400|RENAL ULTRASOUND|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,435.50||| 76775|EAP|0400|RENAL ULTRASOUND|Blue Cross HMO Specialty|BCBSTX HMO|||||1,435.50||| 76775|EAP|0400|RENAL ULTRASOUND|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,435.50||||1,435.50||| 76775|EAP|0400|RENAL ULTRASOUND|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,435.50||| 76775|EAP|0400|RENAL ULTRASOUND|United Healthcare|UNITED HEALTHCARE OTHER|||||1,435.50||| 76775|EAP|0400|RENAL ULTRASOUND|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,435.50||| 76775|EAP|0400|RENAL ULTRASOUND|United Healthcare|TML GROUP BENEFITS|||||1,435.50||| 76775|EAP|0400|RENAL ULTRASOUND|United Healthcare|UNITED HEALTHCARE|||||1,435.50||| 76775|EAP|0400|RENAL ULTRASOUND|United Medicare Advantage|AARP UHC WEST COMPLETE MA|1,435.50||||1,435.50||| 768|DRG||VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C|United Healthcare|UNITED HEALTHCARE OTHER|61,614.30|51.79|51.79|51.79|||| 76801|EAP|0400|US PREG BEFORE 14WKS 0 DA|United Healthcare|UNITED HEALTHCARE|||||1,048.50||| 76801|EAP|0400|US PREG BEFORE 14WKS 0 DA|Workers Compensation|WORKERS COMPENSATION OTHER|||||1,048.50||| 76801|EAP|0400|US PREG BEFORE 14WKS 0 DA|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||1,048.50||| 76801|EAP|0400|US PREG BEFORE 14WKS 0 DA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1,048.50||| 76801|EAP|0400|US PREG BEFORE 14WKS 0 DA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,048.50||||1,048.50||| 76801|EAP|0400|US PREG BEFORE 14WKS 0 DA|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,048.50||| 76801|EAP|0400|US PREG BEFORE 14WKS 0 DA|Blue Cross HMO Specialty|BCBSTX HMO|||||1,048.50||| 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|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1,048.50||| 76801|EAP|0400|US PREG BEFORE 14WKS 0 DA|Humana Medicare Advantage|HUMANA MA|||||1,048.50||| 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|||||1,048.50||| 76801|EAP|0400|US PREG BEFORE 14WKS 0 DA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,048.50||| 76801|EAP|0400|US PREG BEFORE 14WKS 0 DA|United Healthcare|UNITED HEALTHCARE OTHER|||||1,048.50||| 76801|EAP|0400|US PREG BEFORE 14WKS 0 DA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1,048.50||| 76801|EAP|0400|US PREG BEFORE 14WKS 0 DA|Managed Medicaid|MEDICAID SUPERIOR|||||1,048.50||| 76801|EAP|0400|US PREG BEFORE 14WKS 0 DA|NON CONTRACTED|COMMERCIAL OTHER 2|||||1,048.50||| 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|Medicaid|MEDICAID|1,048.50||||1,048.50||| 76801|EAP|0400|US PREG BEFORE 14WKS 0 DA|Tricare|TRICARE EAST REGION|||||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|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||1,048.50||| 76801|EAP|0400|US PREG BEFORE 14WKS 0 DA|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1,048.50||| 76802|EAP|0400|US @ADD GEST BEFORE 14WKS|Medicaid|MEDICAID|||||3.49||| 76802|EAP|0400|US @ADD GEST BEFORE 14WKS|Managed Medicaid|MEDICAID SUPERIOR|||||3.49||| 76802|EAP|0400|US @ADD GEST BEFORE 14WKS|Managed Medicaid|MEDICAID AMERIGROUP|||||3.49||| 76802|EAP|0400|US @ADD GEST BEFORE 14WKS|Blue Cross PPO Specialty|BCBSTX PPO|||||3.49||| 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|UNITED HEALTHCARE OTHER|||||15.12||| 76805|EAP|0400|US PREG AFTER 14WKS 0 DAY|Aetna|AETNA PPO|||||15.12||| 76805|EAP|0400|US PREG AFTER 14WKS 0 DAY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||15.12||| 76805|EAP|0400|US PREG AFTER 14WKS 0 DAY|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||15.12||| 76805|EAP|0400|US PREG AFTER 14WKS 0 DAY|Blue Cross HMO Specialty|BCBSTX HMO|15.12||||15.12||| 76805|EAP|0400|US PREG AFTER 14WKS 0 DAY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||15.12||| 76805|EAP|0400|US PREG AFTER 14WKS 0 DAY|Cigna|CIGNA|||||15.12||| 76805|EAP|0400|US PREG AFTER 14WKS 0 DAY|Blue Cross PPO Specialty|BCBSTX PPO|||||15.12||| 76805|EAP|0400|US PREG AFTER 14WKS 0 DAY|Managed Medicaid|MEDICAID AMERIGROUP|15.12||||15.12||| 76805|EAP|0400|US PREG AFTER 14WKS 0 DAY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||15.12||| 76805|EAP|0400|US PREG AFTER 14WKS 0 DAY|Managed Medicaid|MEDICAID SUPERIOR|15.12||||15.12||| 76805|EAP|0400|US PREG AFTER 14WKS 0 DAY|NON CONTRACTED|COMMERCIAL OTHER 2|||||15.12||| 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|MEDICAID|||||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|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||15.12||| 76805|EAP|0400|US PREG AFTER 14WKS 0 DAY|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||15.12||| 76805|EAP|0400|US PREG AFTER 14WKS 0 DAY|Medicaid|MEDICAID HMO|||||15.12||| 76805|EAP|0400|US PREG AFTER 14WKS 0 DAY|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||15.12||| 76810|EAP|0400|US @ ADD GEST AFTER 14WKS|Managed Medicaid|MEDICAID AMERIGROUP|||||3.49||| 76810|EAP|0400|US @ ADD GEST AFTER 14WKS|Managed Medicaid|MEDICAID SUPERIOR|3.49||||3.49||| 76810|EAP|0400|US @ ADD GEST AFTER 14WKS|Blue Cross PPO Specialty|BCBSTX PPO|||||3.49||| 76815|EAP|0402|LIMITED OBSTETRICAL ASSES|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||4.82||| 76815|EAP|0402|LIMITED OBSTETRICAL ASSES|United Healthcare|UNITED HEALTHCARE|4.82||||||| 76815|EAP|0402|LIMITED OBSTETRICAL ASSES|United Healthcare|UNITED HEALTHCARE OTHER|||||4.82||| 76815|EAP|0402|LIMITED OBSTETRICAL ASSES|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||4.82||| 76815|EAP|0402|LIMITED OBSTETRICAL ASSES|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||4.82||| 76815|EAP|0402|LIMITED OBSTETRICAL ASSES|Blue Cross PPO Specialty|BCBSTX PPO|||||4.82||| 76815|EAP|0402|LIMITED OBSTETRICAL ASSES|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||4.82||| 76815|EAP|0402|LIMITED OBSTETRICAL ASSES|Medicaid|MEDICAID|4.82||||4.82||| 76815|EAP|0402|LIMITED OBSTETRICAL ASSES|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||4.82||| 76815|EAP|0402|LIMITED OBSTETRICAL ASSES|Medicaid|MEDICAID HMO|||||4.82||| 76815|EAP|0402|LIMITED OBSTETRICAL ASSES|Managed Medicaid|MEDICAID SUPERIOR|4.82||||4.82||| 76815|EAP|0402|LIMITED OBSTETRICAL ASSES|Managed Medicaid|MEDICAID AMERIGROUP|4.82||||4.82||| 76816|EAP|0402|PREGNANCY EVALUATION REPE|Managed Medicaid|MEDICAID SUPERIOR|695.50||||695.50||| 76816|EAP|0402|PREGNANCY EVALUATION REPE|Managed Medicaid|MEDICAID AMERIGROUP|695.50||||695.50||| 76816|EAP|0402|PREGNANCY EVALUATION REPE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||695.50||| 76816|EAP|0402|PREGNANCY EVALUATION REPE|NON CONTRACTED|COMMERCIAL OTHER 2|||||695.50||| 76816|EAP|0402|PREGNANCY EVALUATION REPE|Tricare|TRICARE EAST REGION|||||695.50||| 76816|EAP|0402|PREGNANCY EVALUATION REPE|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||695.50||| 76816|EAP|0402|PREGNANCY EVALUATION REPE|Medicaid|MEDICAID|695.50||||695.50||| 76816|EAP|0402|PREGNANCY EVALUATION REPE|NON CONTRACTED|COMMERCIAL OTHER 1|||||695.50||| 76816|EAP|0402|PREGNANCY EVALUATION REPE|Medicaid|MEDICAID TEXAS CHILDRENS|||||695.50||| 76816|EAP|0402|PREGNANCY EVALUATION REPE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||695.50||| 76816|EAP|0402|PREGNANCY EVALUATION REPE|Blue Cross PPO Specialty|BCBSTX PPO|695.50||||695.50||| 76816|EAP|0402|PREGNANCY EVALUATION REPE|Cigna|CIGNA|||||695.50||| 76816|EAP|0402|PREGNANCY EVALUATION REPE|Blue Cross HMO Specialty|BCBSTX HMO|||||695.50||| 76816|EAP|0402|PREGNANCY EVALUATION REPE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||695.50||| 76816|EAP|0402|PREGNANCY EVALUATION REPE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||695.50||| 76816|EAP|0402|PREGNANCY EVALUATION REPE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||695.50||| 76816|EAP|0402|PREGNANCY EVALUATION REPE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||695.50||| 76816|EAP|0402|PREGNANCY EVALUATION REPE|United Healthcare|UNITED HEALTHCARE|695.50||||695.50||| 76816|EAP|0402|PREGNANCY EVALUATION REPE|United Healthcare|UNITED HEALTHCARE OTHER|||||695.50||| 76817|EAP|0400|US TRANSVAGINAL PREG|Workers Compensation|WORKERS COMPENSATION OTHER|||||1,175.75||| 76817|EAP|0400|US TRANSVAGINAL PREG|Blue Cross HMO Specialty|BCBSTX HMO|||||1,175.75||| 76817|EAP|0400|US TRANSVAGINAL PREG|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,175.75||| 76817|EAP|0400|US TRANSVAGINAL PREG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1,175.75||| 76817|EAP|0400|US TRANSVAGINAL PREG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,175.75||||1,175.75||| 76817|EAP|0400|US TRANSVAGINAL PREG|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1,175.75||| 76817|EAP|0400|US TRANSVAGINAL PREG|Blue Cross PPO Specialty|BCBSTX PPO|||||1,175.75||| 76817|EAP|0400|US TRANSVAGINAL PREG|Medicaid|MEDICAID|||||1,175.75||| 76817|EAP|0400|US TRANSVAGINAL PREG|NON CONTRACTED|COMMERCIAL OTHER 1|||||1,175.75||| 76817|EAP|0400|US TRANSVAGINAL PREG|Tricare|TRICARE EAST REGION|||||1,175.75||| 76817|EAP|0400|US TRANSVAGINAL PREG|Medicare|MEDICARE ACUTE|||||1,175.75||| 76817|EAP|0400|US TRANSVAGINAL PREG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,175.75||| 76817|EAP|0400|US TRANSVAGINAL PREG|Managed Medicaid|MEDICAID AMERIGROUP|||||1,175.75||| 76817|EAP|0400|US TRANSVAGINAL PREG|Managed Medicaid|MEDICAID SUPERIOR|||||1,175.75||| 76818|EAP|0403|FETAL BIOPHYSICAL PROFILE|Managed Medicaid|MEDICAID AMERIGROUP|10.50||||10.50||| 76818|EAP|0423||Managed Medicaid|MEDICAID SUPERIOR|||||10.50||| 76818|EAP|0403|FETAL BIOPHYSICAL PROFILE|Managed Medicaid|MEDICAID SUPERIOR|10.50||||10.50||| 76818|EAP|0402||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||10.50||| 76818|EAP|0403|FETAL BIOPHYSICAL PROFILE|Medicaid|MEDICAID|10.50||||||| 76818|EAP|0403|FETAL BIOPHYSICAL PROFILE|Medicaid|MEDICAID TEXAS CHILDRENS|||||10.50||| 76818|EAP|0403|FETAL BIOPHYSICAL PROFILE|NON CONTRACTED|COMMERCIAL OTHER 2|||||10.50||| 76818|EAP|0402||Medicaid|MEDICAID|10.50||||||| 76818|EAP|0403|FETAL BIOPHYSICAL PROFILE|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||10.50||| 76818|EAP|0402||Medicaid|SUPERIOR HEALTHPLAN CHIP|||||10.50||| 76818|EAP|0402||Medicaid|MOLINA HEALTHCARE OF TEXAS|||||10.50||| 76818|EAP|0402||Managed Medicaid|MEDICAID SUPERIOR|10.50||||10.50||| 76818|EAP|0402||NON CONTRACTED|COMMERCIAL OTHER 1|||||10.50||| 76818|EAP|0423||Blue Cross PPO Specialty|BCBSTX PPO|||||10.50||| 76818|EAP|0402||Cigna|CIGNA|||||10.50||| 76818|EAP|0402||Blue Cross PPO Specialty|BCBSTX PPO|10.50||||10.50||| 76818|EAP|0402||Managed Medicaid|MEDICAID AMERIGROUP|10.50||||10.50||| 76818|EAP|0403|FETAL BIOPHYSICAL PROFILE|Cigna|CIGNA|||||10.50||| 76818|EAP|0403|FETAL BIOPHYSICAL PROFILE|Blue Cross PPO Specialty|BCBSTX PPO|||||10.50||| 76818|EAP|0402||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||10.50||| 76818|EAP|0403|FETAL BIOPHYSICAL PROFILE|Blue Cross HMO Specialty|BCBSTX HMO|10.50||||10.50||| 76818|EAP|0403|FETAL BIOPHYSICAL PROFILE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||10.50||| 76818|EAP|0402||Blue Cross HMO Specialty|BCBSTX HMO|||||10.50||| 76818|EAP|0403|FETAL BIOPHYSICAL PROFILE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|10.50||||10.50||| 76818|EAP|0403|FETAL BIOPHYSICAL PROFILE|United Healthcare|UNITED HEALTHCARE|10.50||||||| 76818|EAP|0403|FETAL BIOPHYSICAL PROFILE|United Healthcare|UNITED HEALTHCARE OTHER|||||10.50||| 76818|EAP|0402||United Healthcare|UNITED HEALTHCARE OTHER|||||10.50||| 76819|EAP|0403|FETAL BIOPHYSICAL PROFILE|United Healthcare|UNITED HEALTHCARE OTHER|||||7.90||| 76819|EAP|0403|FETAL BIOPHYSICAL PROFILE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||7.90||| 76819|EAP|0403|FETAL BIOPHYSICAL PROFILE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||7.90||| 76819|EAP|0402||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||7.90||| 76819|EAP|0403|FETAL BIOPHYSICAL PROFILE|Blue Cross PPO Specialty|BCBSTX PPO|||||7.90||| 76819|EAP|0402||Blue Cross PPO Specialty|BCBSTX PPO|||||7.90||| 76819|EAP|0402||Cigna|CIGNA|||||7.90||| 76819|EAP|0403|FETAL BIOPHYSICAL PROFILE|Medicaid|MEDICAID|7.90||||7.90||| 76819|EAP|0403|FETAL BIOPHYSICAL PROFILE|Medicaid|MEDICAID TEXAS CHILDRENS|||||7.90||| 76819|EAP|0402||NON CONTRACTED|COMMERCIAL OTHER 1|||||7.90||| 76819|EAP|0403|FETAL BIOPHYSICAL PROFILE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||7.90||| 76819|EAP|0402||Medicaid|SUPERIOR HEALTHPLAN CHIP|||||7.90||| 76819|EAP|0403|FETAL BIOPHYSICAL PROFILE|Blue Cross HMO Specialty|BCBSTX HMO|||||7.90||| 76819|EAP|0403|FETAL BIOPHYSICAL PROFILE|NON CONTRACTED|COMMERCIAL OTHER 1|||||7.90||| 76819|EAP|0402||Medicaid|MOLINA HEALTHCARE OF TEXAS|||||7.90||| 76819|EAP|0403|FETAL BIOPHYSICAL PROFILE|NON CONTRACTED|COMMERCIAL OTHER 2|||||7.90||| 76819|EAP|0403|FETAL BIOPHYSICAL PROFILE|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||7.90||| 76819|EAP|0403|FETAL BIOPHYSICAL PROFILE|Managed Medicaid|MEDICAID SUPERIOR|7.90||||7.90||| 76819|EAP|0402||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||7.90||| 76819|EAP|0402||Managed Medicaid|MEDICAID SUPERIOR|7.90||||7.90||| 76819|EAP|0403|FETAL BIOPHYSICAL PROFILE|Managed Medicaid|MEDICAID AMERIGROUP|7.90||||7.90||| 76819|EAP|0403|FETAL BIOPHYSICAL PROFILE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||7.90||| 76819|EAP|0423||Managed Medicaid|MEDICAID AMERIGROUP|||||7.90||| 76819|EAP|0402||Managed Medicaid|MEDICAID AMERIGROUP|7.90||||7.90||| 76830|EAP|0400|US TRANSVAGINAL NON PREG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||10.75||| 76830|EAP|0400|US TRANSVAGINAL NON PREG|Managed Medicaid|MEDICAID SUPERIOR|10.75||||10.75||| 76830|EAP|0400|US TRANSVAGINAL NON PREG|Managed Medicare|HEALTHSPRING MA|||||10.75||| 76830|EAP|0400|US TRANSVAGINAL NON PREG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||10.75||| 76830|EAP|0400|US TRANSVAGINAL NON PREG|Medicaid|MEDICAID|||||10.75||| 76830|EAP|0400|US TRANSVAGINAL NON PREG|NON CONTRACTED|COMMERCIAL OTHER 1|||||10.75||| 76830|EAP|0400|US TRANSVAGINAL NON PREG|Managed Medicaid|MEDICAID AMERIGROUP|||||10.75||| 76830|EAP|0400|US TRANSVAGINAL NON PREG|Medicare|MEDICARE ACUTE|||||10.75||| 76830|EAP|0400|US TRANSVAGINAL NON PREG|Rusk State Hospital|RUSK STATE HOSP|||||10.75||| 76830|EAP|0400|US TRANSVAGINAL NON PREG|Cigna|CIGNA|||||10.75||| 76830|EAP|0400|US TRANSVAGINAL NON PREG|Blue Cross PPO Specialty|BCBSTX PPO|||||10.75||| 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|||||10.75||| 76830|EAP|0400|US TRANSVAGINAL NON PREG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||10.75||| 76830|EAP|0400|US TRANSVAGINAL NON PREG|Aenta Medicare Advantage|AETNA MEDICARE MA|||||10.75||| 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|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||10.75||| 76830|EAP|0400|US TRANSVAGINAL NON PREG|United Medicare Advantage|UHC MEDICARE GOLD MA|||||10.75||| 76830|EAP|0400|US TRANSVAGINAL NON PREG|United Healthcare|UNITED HEALTHCARE|||||10.75||| 76830|EAP|0400|US TRANSVAGINAL NON PREG|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||10.75||| 76830|EAP|0400|US TRANSVAGINAL NON PREG|United Healthcare|UNITED HEALTHCARE OTHER|||||10.75||| 76856|EAP|0402|PELVIC ULTRASOUND|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||15.12||| 76856|EAP|0402|PELVIC ULTRASOUND|United Medicare Advantage|UHC MEDICARE GOLD MA|||||15.12||| 76856|EAP|0402|PELVIC ULTRASOUND|United Healthcare|UNITED HEALTHCARE|||||15.12||| 76856|EAP|0402|PELVIC ULTRASOUND|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||15.12||| 76856|EAP|0402|PELVIC ULTRASOUND|United Healthcare|UNITED HEALTHCARE OTHER|||||15.12||| 76856|EAP|0402|PELVIC ULTRASOUND|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||15.12||| 76856|EAP|0402|PELVIC ULTRASOUND|Blue Cross HMO Specialty|BCBSTX HMO|||||15.12||| 76856|EAP|0402|PELVIC ULTRASOUND|Aenta Medicare Advantage|AETNA MEDICARE MA|||||15.12||| 76856|EAP|0402|PELVIC ULTRASOUND|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||15.12||| 76856|EAP|0402|PELVIC ULTRASOUND|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||15.12||| 76856|EAP|0402|PELVIC ULTRASOUND|Cigna|CIGNA|||||15.12||| 76856|EAP|0402|PELVIC ULTRASOUND|Blue Cross PPO Specialty|BCBSTX PPO|||||15.12||| 76856|EAP|0402|PELVIC ULTRASOUND|Humana Medicare Advantage|HUMANA MA|||||15.12||| 76856|EAP|0402|PELVIC ULTRASOUND|Blue Cross PPO Specialty|BCBSTX OTHER|||||15.12||| 76856|EAP|0402|PELVIC ULTRASOUND|Medicare|MEDICARE ACUTE|||||15.12||| 76856|EAP|0402|PELVIC ULTRASOUND|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||15.12||| 76856|EAP|0402|PELVIC ULTRASOUND|Medicaid|MEDICAID|15.12||||15.12||| 76856|EAP|0402|PELVIC ULTRASOUND|NON CONTRACTED|COMMERCIAL OTHER 1|||||15.12||| 76856|EAP|0402|PELVIC ULTRASOUND|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||15.12||| 76856|EAP|0402|PELVIC ULTRASOUND|Rusk State Hospital|RUSK STATE HOSP|||||15.12||| 76856|EAP|0402|PELVIC ULTRASOUND|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||15.12||| 76856|EAP|0402|PELVIC ULTRASOUND|Managed Medicare|HEALTHSPRING MA|||||15.12||| 76856|EAP|0402|PELVIC ULTRASOUND|Managed Medicaid|MEDICAID SUPERIOR|15.12||||15.12||| 76856|EAP|0402|PELVIC ULTRASOUND|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||15.12||| 76856|EAP|0402|PELVIC ULTRASOUND|Managed Medicaid|MEDICAID AMERIGROUP|15.12||||15.12||| 76857|EAP|0402|US PELVIS LIMITED|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||631.25||| 76857|EAP|0402|US PELVIS LIMITED|Medicare|MEDICARE ACUTE|||||631.25||| 76857|EAP|0402|US PELVIS LIMITED|Blue Cross PPO Specialty|BCBSTX PPO|||||631.25||| 76857|EAP|0402|US PELVIS LIMITED|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||631.25||| 76870|EAP|0400|SCROTUM ULTRASOUND|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||864.50||| 76870|EAP|0400|SCROTUM ULTRASOUND|United Healthcare|UNITED HEALTHCARE OTHER|||||864.50||| 76870|EAP|0400|SCROTUM ULTRASOUND|Blue Cross HMO Specialty|BCBSTX HMO|||||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|864.50||||864.50||| 76870|EAP|0400|SCROTUM ULTRASOUND|Blue Cross PPO Specialty|BCBSTX OTHER|||||864.50||| 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|||||864.50||| 76870|EAP|0400|SCROTUM ULTRASOUND|Medicaid|MEDICAID HMO|||||864.50||| 76870|EAP|0400|SCROTUM ULTRASOUND|Medicare|MEDICARE ACUTE|864.50||||864.50||| 76870|EAP|0400|SCROTUM ULTRASOUND|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||864.50||| 76870|EAP|0400|SCROTUM ULTRASOUND|Medicaid|MEDICAID|864.50||||864.50||| 76870|EAP|0400|SCROTUM ULTRASOUND|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||864.50||| 76870|EAP|0400|SCROTUM ULTRASOUND|Medicaid|MEDICAID TEXAS CHILDRENS|||||864.50||| 76870|EAP|0400|SCROTUM ULTRASOUND|NON CONTRACTED|COMMERCIAL OTHER 1|||||864.50||| 76870|EAP|0400|SCROTUM ULTRASOUND|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||864.50||| 76870|EAP|0400|SCROTUM ULTRASOUND|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||864.50||| 76870|EAP|0400|SCROTUM ULTRASOUND|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||864.50||| 76870|EAP|0400|SCROTUM ULTRASOUND|Managed Medicaid|MEDICAID AMERIGROUP|||||864.50||| 76870|EAP|0400|SCROTUM ULTRASOUND|Managed Medicaid|MEDICAID SUPERIOR|||||864.50||| 76881|EAP|0400|US SOFT TISSUE EXTREMITY|Managed Medicaid|MEDICAID SUPERIOR|||||2.68||| 76881|EAP|0400|US SOFT TISSUE EXTREMITY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||2.68||| 76881|EAP|0400|US SOFT TISSUE EXTREMITY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||2.68||| 76881|EAP|0400|US SOFT TISSUE EXTREMITY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||2.68||| 76881|EAP|0400|US SOFT TISSUE EXTREMITY|Managed Medicaid|MEDICAID AMERIGROUP|||||2.68||| 76881|EAP|0400|US SOFT TISSUE EXTREMITY|Medicare|MEDICARE ACUTE|2.68||||2.68||| 76881|EAP|0400|US SOFT TISSUE EXTREMITY|NON CONTRACTED|COMMERCIAL OTHER 1|||||2.68||| 76881|EAP|0400|US SOFT TISSUE EXTREMITY|Humana Medicare Advantage|HUMANA MA|||||2.68||| 76881|EAP|0400|US SOFT TISSUE EXTREMITY|Blue Cross PPO Specialty|BCBSTX PPO|||||2.68||| 76881|EAP|0400|US SOFT TISSUE EXTREMITY|Blue Cross HMO Specialty|BCBSTX HMO|||||2.68||| 76881|EAP|0400|US SOFT TISSUE EXTREMITY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||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|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2.68||| 76881|EAP|0400|US SOFT TISSUE EXTREMITY|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||2.68||| 76881|EAP|0400|US SOFT TISSUE EXTREMITY|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||2.68||| 76881|EAP|0400|US SOFT TISSUE EXTREMITY|United Medicare Advantage|UHC MEDICARE GOLD MA|||||2.68||| 769|DRG||POSTPARTUM & POST ABORTION DIAGNOSES W O.R. PROCEDURE|Managed Medicaid|MEDICAID AMERIGROUP|29,838.25|15061.29|15061.29|15061.29|||| 76937|EAP|0400|US GUIDE/EVAL VASCULAR AC|Medicare|MEDICARE ACUTE|6.56||||6.56||| 76937|EAP|0400|US GUIDE/EVAL VASCULAR AC|Rusk State Hospital|RUSK STATE HOSP|6.56||||||| 76937|EAP|0400|US GUIDE/EVAL VASCULAR AC|Managed Medicare|HEALTHSPRING MA|6.56||||||| 76937|EAP|0400|US GUIDE/EVAL VASCULAR AC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|6.56||||||| 76937|EAP|0400|US GUIDE/EVAL VASCULAR AC|Veterans Affairs|VETERANS ADMINISTRATION|6.56||||||| 76937|EAP|0400|US GUIDE/EVAL VASCULAR AC|United Medicare Advantage|AARP UHC WEST COMPLETE MA|6.56||||||| 76937|EAP|0400|US GUIDE/EVAL VASCULAR AC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6.56||||||| 76937|EAP|0400|US GUIDE/EVAL VASCULAR AC|Humana Medicare Advantage|HUMANA MA|6.56||||||| 76937|EAP|0400|US GUIDE/EVAL VASCULAR AC|Blue Cross PPO Specialty|BCBSTX PPO|||||6.56||| 76937|EAP|0400|US GUIDE/EVAL VASCULAR AC|Brinson Benefits|THE HEALTH PLAN SMITH CO|6.56||||||| 76942|EAP|0400|US GUIDED BIOPSY ASPIRATI|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||419.50||| 770|DRG||ABORTION W D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY|Medicaid|MEDICAID|30,391.20|6183.54|6183.54|6183.54|||| 77065|EAP|0401|DIAGNOSTIC MAMMO LEFT W/C|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||4.35||| 77065|EAP|0401|DIAGNOSTIC MAMMO LEFT W/C|Blue Cross PPO Specialty|BCBSTX PPO|||||4.35||| 77065|EAP|0401|MAMMO DIGITAL RT METL CLI|Humana Medicare Advantage|HUMANA MA|||||2.78||| 77065|EAP|0401|DIAGNOSTIC MAMMO RIGHT W/|Humana Medicare Advantage|HUMANA MA|||||4.35||| 77065|EAP|0401|DIAGNOSTIC MAMMO LEFT W/C|Humana Medicare Advantage|HUMANA MA|||||4.35||| 77065|EAP|0401|DIAGNOSTIC MAMMO RIGHT W/|Blue Cross PPO Specialty|BCBSTX PPO|||||4.35||| 77065|EAP|0401|DIAGNOSTIC MAMMO RIGHT W/|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||4.35||| 77065|EAP|0401|DIAGNOSTIC MAMMO LEFT W/C|Blue Cross HMO Specialty|BCBSTX HMO|||||4.35||| 77065|EAP|0401|DIAGNOSTIC MAMMO LEFT W/C|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||4.35||| 77065|EAP|0401|DIAGNOSTIC MAMMO LEFT W/C|Aenta Medicare Advantage|AETNA MEDICARE MA|||||4.35||| 77065|EAP|0401|DIAGNOSTIC MAMMO RIGHT W/|Blue Cross HMO Specialty|BCBSTX HMO|||||4.35||| 77065|EAP|0401|DIAGNOSTIC MAMMO RIGHT W/|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||4.35||| 77065|EAP|0401|DIAGNOSTIC MAMMO LEFT W/C|Aetna|AETNA PPO|||||4.35||| 77065|EAP|0401|DIAGNOSTIC MAMMO LEFT W/C|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||4.35||| 77065|EAP|0401|DIAGNOSTIC MAMMO RIGHT W/|United Healthcare|UNITED HEALTHCARE|||||4.35||| 77065|EAP|0401|DIAGNOSTIC MAMMO RIGHT W/|United Medicare Advantage|UHC MEDICARE GOLD MA|||||4.35||| 77065|EAP|0401|DIAGNOSTIC MAMMO LEFT W/C|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||4.35||| 77065|EAP|0401|DIAGNOSTIC MAMMO RIGHT W/|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||4.35||| 77065|EAP|0401|DIAGNOSTIC MAMMO LEFT W/C|United Medicare Advantage|UHC MEDICARE GOLD MA|||||4.35||| 77065|EAP|0401|DIAGNOSTIC MAMMO LEFT W/C|Cigna|CIGNA|||||4.35||| 77065|EAP|0401|DIAGNOSTIC MAMMO LEFT W/C|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||4.35||| 77065|EAP|0401|DIAGNOSTIC MAMMO RIGHT W/|Veterans Affairs|VETERANS ADMINISTRATION|||||4.35||| 77065|EAP|0401|MAMMO DIGITAL RT METL CLI|Blue Cross PPO Specialty|BCBSTX PPO|||||2.78||| 77065|EAP|0401|DIAGNOSTIC MAMMO LEFT W/C|United Healthcare|UNITED HEALTHCARE OTHER|||||4.35||| 77065|EAP|0401|MAMMO DIGITAL RT METL CLI|Medicare|MEDICARE ACUTE|||||2.78||| 77065|EAP|0401|DIAGNOSTIC MAMMO RIGHT W/|NON CONTRACTED|COMMERCIAL OTHER 1|||||4.35||| 77065|EAP|0401|MAMMO DIGITAL RT METL CLI|NON CONTRACTED|COMMERCIAL OTHER 1|||||2.78||| 77065|EAP|0401|DIAGNOSTIC MAMMO LEFT W/C|NON CONTRACTED|COMMERCIAL OTHER 1|||||4.35||| 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|||||4.35||| 77065|EAP|0401|DIAGNOSTIC MAMMO RIGHT W/|Medicare|MEDICARE ACUTE|||||4.35||| 77065|EAP|0401|DIAGNOSTIC MAMMO RIGHT W/|Managed Medicare|HEALTHSPRING MA|||||4.35||| 77065|EAP|0401|DIAG MAMMO RIGHT DIGITAL|Managed Medicaid|MEDICAID SUPERIOR|||||387.25||| 77065|EAP|0401|DIAGNOSTIC MAMMO RIGHT W/|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||4.35||| 77065|EAP|0401|MAMMO DIGITAL RT METL CLI|Managed Medicare|HEALTHSPRING MA|||||2.78||| 77065|EAP|0401|DIAGNOSTIC MAMMO RIGHT W/|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||4.35||| 77065|EAP|0401|DIAGNOSTIC MAMMO RIGHT W/|Managed Medicaid|MEDICAID SUPERIOR|||||4.35||| 77065|EAP|0401|MAMMO DIGITAL RT METL CLI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||2.78||| 77066|EAP|0401|DIAGNOSTIC MAMMO BILAT W/|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||5.35||| 77066|EAP|0401|DIAGNOSTIC MAMMO BILAT W/|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||5.35||| 77066|EAP|0403|SCREEN MAMO/IMPLANTS/BIL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||4.62||| 77066|EAP|0403|SCREEN MAMO/IMPLANTS/BIL|Managed Medicaid|MEDICAID SUPERIOR|||||4.62||| 77066|EAP|0401|DIAGNOSTIC MAMMO BILAT W/|Managed Medicaid|MEDICAID AMERIGROUP|||||5.35||| 77066|EAP|0403|SCREEN MAMO/IMPLANTS/BIL|Tricare|TRICARE EAST REGION|||||4.62||| 77066|EAP|0401|DIAGNOSTIC MAMMO BILAT W/|Medicare|MEDICARE ACUTE|||||5.35||| 77066|EAP|0401|DIAGNOSTIC MAMMO BILAT W/|NON CONTRACTED|COMMERCIAL OTHER 1|||||5.35||| 77066|EAP|0403|SCREEN MAMO/IMPLANTS/BIL|Medicare|MEDICARE ACUTE|||||4.62||| 77066|EAP|0403|SCREEN MAMO/IMPLANTS/BIL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||4.62||| 77066|EAP|0403|SCREEN MAMO/IMPLANTS/BIL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||4.62||| 77066|EAP|0401|DIAGNOSTIC MAMMO BILAT W/|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||5.35||| 77066|EAP|0403|SCREEN MAMO/IMPLANTS/BIL|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||4.62||| 77066|EAP|0403|SCREEN MAMO/IMPLANTS/BIL|NON CONTRACTED|COMMERCIAL OTHER 1|||||4.62||| 77066|EAP|0401|DIAGNOSTIC MAMMO BILAT W/|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||5.35||| 77066|EAP|0401|DIAGNOSTIC MAMMO BILAT W/|United Medicare Advantage|UHC MEDICARE GOLD MA|||||5.35||| 77066|EAP|0401|DIAGNOSTIC MAMMO BILAT W/|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||5.35||| 77066|EAP|0401|DIAGNOSTIC MAMMO BILAT W/|Managed Medicaid|MEDICAID SUPERIOR|||||5.35||| 77066|EAP|0401|DIAGNOSTIC MAMMO BILAT W/|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||5.35||| 77066|EAP|0401|DIAGNOSTIC MAMMO BILAT W/|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||5.35||| 77066|EAP|0403|SCREEN MAMO/IMPLANTS/BIL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||4.62||| 77066|EAP|0401|DIAGNOSTIC MAMMO BILAT W/|Blue Cross HMO Specialty|BCBSTX HMO|||||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/|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||5.35||| 77066|EAP|0401|DIAGNOSTIC MAMMO BILAT W/|Humana Medicare Advantage|HUMANA MA|||||5.35||| 77066|EAP|0403|SCREEN MAMO/IMPLANTS/BIL|Humana Medicare Advantage|HUMANA MA|||||4.62||| 77066|EAP|0403|SCREEN MAMO/IMPLANTS/BIL|Blue Cross PPO Specialty|BCBSTX PPO|||||4.62||| 77066|EAP|0401|DIAGNOSTIC MAMMO BILAT W/|Blue Cross PPO Specialty|BCBSTX PPO|||||5.35||| 77066|EAP|0401|DIAGNOSTIC MAMMO BILAT W/|Cigna|CIGNA|||||5.35||| 77067|EAP|0403|SCREENING MAMMO RIGHT W/C|Humana Medicare Advantage|HUMANA MA|5.35||||4.35||| 77067|EAP|0403|SCREENING MAMMO RIGHT W/C|Blue Cross PPO Specialty|BCBSTX PPO|||||4.35||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||5.35||| 77067|EAP|0403|SCREENING MAMMO LEFT W/CA|Humana Medicare Advantage|HUMANA MA|5.35||||4.35||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|Humana Medicare Advantage|HUMANA MA|5.35||||5.35||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|Blue Cross PPO Specialty|BCBSTX PPO|||||5.35||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|Blue Cross PPO Specialty|BCBSTX OTHER|||||5.35||| 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|Access Direct Platinum|HEALTHFIRST TPA UMR|||||5.35||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|Blue Cross HMO Specialty|BCBSTX HMO|||||5.35||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||5.35||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|Aetna|AETNA OTHER|||||5.35||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|Aetna|BOON CHAPMAN|||||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|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||5.35||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||5.35||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|Aetna|AETNA PPO|||||5.35||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|Veterans Affairs|VETERANS ADMINISTRATION|||||5.35||| 77067|EAP|0403|SCREENING MAMMO RIGHT W/C|United Medicare Advantage|UHC MEDICARE GOLD MA|||||4.35||| 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 LEFT W/CA|United Medicare Advantage|UHC MEDICARE GOLD MA|||||4.35||| 77067|EAP|0403|SCREENING MAMMO RIGHT W/C|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||4.35||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|United Healthcare|GEHA|||||5.35||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|United Medicare Advantage|UHC MEDICARE GOLD MA|||||5.35||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|Aenta Medicare Advantage|AETNA MEDICARE MA|||||5.35||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|United Healthcare|UNITED HEALTHCARE OTHER|||||5.35||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||5.35||| 77067|EAP|0403|SCREENING MAMMO LEFT W/CA|Blue Cross PPO Specialty|BCBSTX PPO|||||4.35||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|PHCS|HUMANA INSURANCE|||||5.35||| 77067|EAP|0403|SCREENING MAMMO RIGHT W/C|Medicare|MEDICARE ACUTE|||||4.35||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|Cigna|CIGNA|||||5.35||| 77067|EAP|0403|SCREENING MAMMO LEFT W/CA|Medicare|MEDICARE ACUTE|||||4.35||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|Medicaid|MEDICAID|||||5.35||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|Medicare|MEDICARE ACUTE|||||5.35||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|NON CONTRACTED|COMMERCIAL OTHER 1|||||5.35||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|Tricare|TRICARE EAST REGION|||||5.35||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|Managed Medicaid|MEDICAID AMERIGROUP|||||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 Medicaid|MEDICAID CIGNA HEALTHSPRING|||||5.35||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|Managed Medicare|BCBS MEDICARE PPO MA|||||5.35||| 77067|EAP|0403|SCREENING MAMMO LEFT W/CA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||4.35||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|Managed Medicare|HEALTHSPRING MA|||||5.35||| 77067|EAP|0403|SCREENING MAMMO BILAT W/C|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||5.35||| 77072|EAP|0320|BONE AGE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||515.75||| 77072|EAP|0320|BONE AGE|Managed Medicaid|MEDICAID SUPERIOR|||||515.75||| 77072|EAP|0320|BONE AGE|Managed Medicaid|MEDICAID AMERIGROUP|||||515.75||| 77072|EAP|0320|BONE AGE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||515.75||| 77074|EAP|0320|BONE SURVEY LIMITED|Managed Medicaid|MEDICAID AMERIGROUP|||||8.00||| 77075|EAP|0320|BONE SURVEY COMPLETE|Medicare|MEDICARE ACUTE|11.00||||11.00||| 77075|EAP|0320|BONE SURVEY COMPLETE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||11.00||| 77076|EAP|0320|INFANT BONE SURVEY|Managed Medicaid|MEDICAID AMERIGROUP|||||489.50||| 77076|EAP|0320|INFANT BONE SURVEY|Managed Medicaid|MEDICAID SUPERIOR|||||489.50||| 77080|EAP|0320|BONE DENSITY HIP PELVIS S|United Healthcare|UNITED HEALTHCARE OTHER|||||454.25||| 77080|EAP|0320|BONE DENSITY HIP PELVIS S|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||454.25||| 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|Aetna|AETNA OTHER|||||454.25||| 77080|EAP|0320|BONE DENSITY HIP PELVIS S|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||454.25||| 77080|EAP|0320|BONE DENSITY HIP PELVIS S|Aenta Medicare Advantage|AETNA MEDICARE MA|||||454.25||| 77080|EAP|0320|BONE DENSITY HIP PELVIS S|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||454.25||| 77080|EAP|0320|BONE DENSITY HIP PELVIS S|Blue Cross HMO Specialty|BCBSTX HMO|||||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|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||454.25||| 77080|EAP|0320|BONE DENSITY HIP PELVIS S|Blue Cross PPO Specialty|BCBSTX PPO|||||454.25||| 77080|EAP|0320|BONE DENSITY HIP PELVIS S|Blue Cross PPO Specialty|BCBSTX OTHER|||||454.25||| 77080|EAP|0320|BONE DENSITY HIP PELVIS S|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||454.25||| 77080|EAP|0320|BONE DENSITY HIP PELVIS S|Humana Medicare Advantage|HUMANA MA|||||454.25||| 77080|EAP|0320|BONE DENSITY HIP PELVIS S|Cigna|CIGNA|||||454.25||| 77080|EAP|0320|BONE DENSITY HIP PELVIS S|Tricare|TRICARE EAST REGION|||||454.25||| 77080|EAP|0320|BONE DENSITY HIP PELVIS S|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||454.25||| 77080|EAP|0320|BONE DENSITY HIP PELVIS S|PHCS|HUMANA INSURANCE|||||454.25||| 77080|EAP|0320|BONE DENSITY HIP PELVIS S|Medicare|MEDICARE ACUTE|||||454.25||| 77080|EAP|0320|BONE DENSITY HIP PELVIS S|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||454.25||| 77080|EAP|0320|BONE DENSITY HIP PELVIS S|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||454.25||| 77080|EAP|0320|BONE DENSITY HIP PELVIS S|Managed Medicare|HEALTHSPRING MA|||||454.25||| 77080|EAP|0320|BONE DENSITY HIP PELVIS S|Managed Medicaid|MEDICAID AMERIGROUP|||||454.25||| 77080|EAP|0320|BONE DENSITY HIP PELVIS S|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||454.25||| 77081|EAP|0320|BONE DENSITY RADIUS WRIST|Medicare|MEDICARE ACUTE|||||454.25||| 776|DRG||POSTPARTUM & POST ABORTION DIAGNOSES W/O O.R. PROCEDURE|Managed Medicaid|MEDICAID SUPERIOR|288.23|6159.48|16763.66|2730.24|||| 776|DRG||POSTPARTUM & POST ABORTION DIAGNOSES W/O O.R. PROCEDURE|Managed Medicaid|MEDICAID AMERIGROUP|20,333.75|16763.66|16763.66|2730.24|||| 776|DRG||POSTPARTUM & POST ABORTION DIAGNOSES W/O O.R. PROCEDURE|Blue Cross PPO Specialty|BCBSTX PPO|26,861.25|2730.24|16763.66|2730.24|||| 776|DRG||POSTPARTUM & POST ABORTION DIAGNOSES W/O O.R. PROCEDURE|Medicaid|MEDICAID|84,887.25|3857.5|16763.66|2730.24|||| 78014|EAP|0341|THYROID IMAGING W/UPTAKE|NON CONTRACTED|COMMERCIAL OTHER 1|||||2,142.75||| 78014|EAP|0341|THYROID IMAGING W/UPTAKE|Medicare|MEDICARE ACUTE|||||2,142.75||| 78014|EAP|0341|THYROID IMAGING W/UPTAKE|United Healthcare|UNITED HEALTHCARE|||||2,142.75||| 78014|EAP|0341|THYROID IMAGING W/UPTAKE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||2,142.75||| 78014|EAP|0341|THYROID IMAGING W/UPTAKE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2,142.75||| 78014|EAP|0341|THYROID IMAGING W/UPTAKE|Blue Cross PPO Specialty|BCBSTX PPO|||||2,142.75||| 78014|EAP|0341|THYROID IMAGING W/UPTAKE|Humana Medicare Advantage|HUMANA MA|||||2,142.75||| 78227|EAP|0341|HIDA W/CCK|Blue Cross PPO Specialty|BCBSTX PPO|||||3,143.25||| 78227|EAP|0341|HIDA W/CCK|Cigna|CIGNA|||||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|Blue Cross HMO Specialty|BCBSTX HMO|||||3,143.25||| 78227|EAP|0341|HIDA W/CCK|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||3,143.25||| 78227|EAP|0341|HIDA W/CCK|Aetna|AETNA OTHER|||||3,143.25||| 78227|EAP|0341|HIDA W/CCK|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||3,143.25||| 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|Managed Medicaid|MEDICAID SUPERIOR|||||3,143.25||| 78227|EAP|0341|HIDA W/CCK|Managed Medicaid|MEDICAID AMERIGROUP|||||3,143.25||| 78227|EAP|0341|HIDA W/CCK|NON CONTRACTED|COMMERCIAL OTHER 1|||||3,143.25||| 78227|EAP|0341|HIDA W/CCK|Medicare|MEDICARE ACUTE|3,143.25||||3,143.25||| 783|DRG||CESAREAN SECTION W STERILIZATION W MCC|Medicaid|MEDICAID|34,944.65|9111.89|9111.89|45.66|||| 783|DRG||CESAREAN SECTION W STERILIZATION W MCC|Blue Cross PPO Specialty|BCBSTX PPO|33,861.45|45.66|9111.89|45.66|||| 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|AARP UHC WEST COMPLETE MA|||||27.11||| 78306|EAP|0341|BONE IMAGING WHOLE BODY|Humana Medicare Advantage|HUMANA MA|||||27.11||| 78306|EAP|0341|BONE IMAGING WHOLE BODY|Cigna|CIGNA|||||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 HMO Specialty|BCBSTX HMO|||||27.11||| 78306|EAP|0341|BONE IMAGING WHOLE BODY|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||27.11||| 78306|EAP|0341|BONE IMAGING WHOLE BODY|Medicare|MEDICARE ACUTE|27.11||||27.11||| 78306|EAP|0341|BONE IMAGING WHOLE BODY|Medicaid|MEDICAID|||||27.11||| 78306|EAP|0341|BONE IMAGING WHOLE BODY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||27.11||| 78306|EAP|0341|BONE IMAGING WHOLE BODY|Managed Medicare|HEALTHSPRING MA|||||27.11||| 78315|EAP|0341|BONE 3 PHASE|Tricare|TRICARE EAST REGION|||||1,979.50||| 784|DRG||CESAREAN SECTION W STERILIZATION W CC|Managed Medicaid|MEDICAID SUPERIOR|38,975.40|14487.91|14487.91|37.8|||| 784|DRG||CESAREAN SECTION W STERILIZATION W CC|Cigna|CIGNA|53,194.20|37.8|14487.91|37.8|||| 784|DRG||CESAREAN SECTION W STERILIZATION W CC|Managed Medicaid|MEDICAID AMERIGROUP|35,225.78|14487.91|14487.91|37.8|||| 784|DRG||CESAREAN SECTION W STERILIZATION W CC|Medicaid|MEDICAID|32,429.10|9111.89|14487.91|37.8|||| 784|DRG||CESAREAN SECTION W STERILIZATION W CC|United Healthcare|UNITED HEALTHCARE|30,616.75|73.28|14487.91|37.8|||| 78445|EAP|0341|BLOOD FLOW|Tricare|TRICARE EAST REGION|||||7.17||| 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|United Medicare Advantage|UHC MEDICARE GOLD 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|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||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|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||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||||6,381.50||| 78452|EAP|0341|CARDIAC SPECT PERF R&S|Blue Cross PPO Specialty|BCBSTX PPO|||||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|United Healthcare|UNITED HEALTHCARE|||||6,381.50||| 78452|EAP|0341|CARDIAC SPECT PERF R&S|Humana Medicare Advantage|HUMANA MA|6,381.50||||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|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||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 Medicaid|MEDICAID SUPERIOR|||||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 Medicare|HEALTHSPRING MA|||||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|NON CONTRACTED|COMMERCIAL OTHER 1|||||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|Medicare|MEDICARE ACUTE|6,381.50||||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|UTMB|UTMB CORRECTIONAL MANAGED CARE|6,381.50||||||| 785|DRG||CESAREAN SECTION W STERILIZATION W/O CC/MCC|NON CONTRACTED|COMMERCIAL OTHER 1|45,092.60|43.05|10925.59|43.05|||| 785|DRG||CESAREAN SECTION W STERILIZATION W/O CC/MCC|Medicaid|MEDICAID|35,707.80|6871.44|10925.59|43.05|||| 785|DRG||CESAREAN SECTION W STERILIZATION W/O CC/MCC|Managed Medicaid|MEDICAID AMERIGROUP|27,867.35|10925.59|10925.59|43.05|||| 785|DRG||CESAREAN SECTION W STERILIZATION W/O CC/MCC|Managed Medicaid|MEDICAID SUPERIOR|20,855.65|10925.59|10925.59|43.05|||| 785|DRG||CESAREAN SECTION W STERILIZATION W/O CC/MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|30,898.65|10925.59|10925.59|43.05|||| 785|DRG||CESAREAN SECTION W STERILIZATION W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|43,137.65|3215.44|10925.59|43.05|||| 785|DRG||CESAREAN SECTION W STERILIZATION W/O CC/MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|16,725.45|7751.54|10925.59|43.05|||| 785|DRG||CESAREAN SECTION W STERILIZATION W/O CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|35,633.05|2977.85|10925.59|43.05|||| 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|Aetna|AETNA PPO|||||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|Medicare|MEDICARE ACUTE|||||35.39||| 786|DRG||CESAREAN SECTION W/O STERILIZATION W MCC|Managed Medicaid|MEDICAID SUPERIOR|41,657.75|20828.13|20828.13|4788.04|||| 786|DRG||CESAREAN SECTION W/O STERILIZATION W MCC|Blue Cross PPO Specialty|BCBSTX PPO|61,507.75|4788.04|20828.13|4788.04|||| 787|DRG||CESAREAN SECTION W/O STERILIZATION W CC|Medicaid|MEDICAID|31,605.10|6871.44|11803.535|6871.44|||| 787|DRG||CESAREAN SECTION W/O STERILIZATION W CC|Managed Medicaid|MEDICAID AMERIGROUP|28,243.55|10925.59|11803.535|6871.44|||| 787|DRG||CESAREAN SECTION W/O STERILIZATION W CC|Managed Medicaid|MEDICAID SUPERIOR|35,517.80|11803.535|11803.535|6871.44|||| 78708|EAP|0341|RENAL SCAN|Blue Cross PPO Specialty|BCBSTX PPO|||||13.21||| 788|DRG||CESAREAN SECTION W/O STERILIZATION W/O CC/MCC|Medicaid|MEDICAID|31,549.18|6871.44|10925.59|3172.27|||| 788|DRG||CESAREAN SECTION W/O STERILIZATION W/O CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|32,564.55|3172.27|10925.59|3172.27|||| 788|DRG||CESAREAN SECTION W/O STERILIZATION W/O CC/MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|31,654.55|8084.78|10925.59|3172.27|||| 788|DRG||CESAREAN SECTION W/O STERILIZATION W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|34,879.45|3425.36|10925.59|3172.27|||| 788|DRG||CESAREAN SECTION W/O STERILIZATION W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|44,779.15|3731.6|10925.59|3172.27|||| 788|DRG||CESAREAN SECTION W/O STERILIZATION W/O CC/MCC|Managed Medicaid|MEDICAID AMERIGROUP|37,136.60|10925.59|10925.59|3172.27|||| 788|DRG||CESAREAN SECTION W/O STERILIZATION W/O CC/MCC|Managed Medicaid|MEDICAID SUPERIOR|35,720.90|10925.59|10925.59|3172.27|||| 789|DRG||NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY|Managed Medicaid|MEDICAID SUPERIOR|6,955.35|3476.74|10256.08|1440.21|||| 789|DRG||NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY|Managed Medicaid|MEDICAID AMERIGROUP|35,000.85|10256.08|10256.08|1440.21|||| 789|DRG||NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY|Medicaid|MEDICAID|5,979.85|1440.21|10256.08|1440.21|||| 78999|EAP|0341|DELAYED SCAN|Medicare|MEDICARE ACUTE|||||349.75||| 78999|EAP|0341|DELAYED SCAN|United Healthcare|UNITED HEALTHCARE|||||349.75||| 78999|EAP|0341|DELAYED SCAN|United Medicare Advantage|UHC MEDICARE GOLD MA|||||349.75||| 78999|EAP|0341|DELAYED SCAN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||349.75||| 78999|EAP|0341|DELAYED SCAN|Blue Cross PPO Specialty|BCBSTX PPO|||||349.75||| 78999|EAP|0341|DELAYED SCAN|Humana Medicare Advantage|HUMANA MA|||||349.75||| 791|DRG||PREMATURITY W MAJOR PROBLEMS|Managed Medicaid|MEDICAID AMERIGROUP|12,251.73|8456.78|8456.78|8456.78|||| 792|DRG||PREMATURITY W/O MAJOR PROBLEMS|Medicaid|MEDICAID|11,489.35|1440.21|2549.72|21.44|||| 792|DRG||PREMATURITY W/O MAJOR PROBLEMS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8,984.10|21.44|2549.72|21.44|||| 792|DRG||PREMATURITY W/O MAJOR PROBLEMS|Managed Medicaid|MEDICAID AMERIGROUP|16,157.23|2035.8|2549.72|21.44|||| 792|DRG||PREMATURITY W/O MAJOR PROBLEMS|Managed Medicaid|MEDICAID SUPERIOR|9,971.85|2549.72|2549.72|21.44|||| 793|DRG||FULL TERM NEONATE W MAJOR PROBLEMS|Managed Medicaid|MEDICAID SUPERIOR|14,462.50|14462.5|14462.5|41.13|||| 793|DRG||FULL TERM NEONATE W MAJOR PROBLEMS|Managed Medicaid|MEDICAID AMERIGROUP|12,849.10|2549.72|14462.5|41.13|||| 793|DRG||FULL TERM NEONATE W MAJOR PROBLEMS|Blue Cross PPO Specialty|BCBSTX PPO|12,518.60|41.13|14462.5|41.13|||| 793|DRG||FULL TERM NEONATE W MAJOR PROBLEMS|Medicaid|MEDICAID|10,055.05|1603.6|14462.5|41.13|||| 794|DRG||NEONATE W OTHER SIGNIFICANT PROBLEMS|Medicaid|MEDICAID|9,164.35|2016.29|11414.41|23.3|||| 794|DRG||NEONATE W OTHER SIGNIFICANT PROBLEMS|Blue Cross PPO Specialty|BCBSTX PPO|9,759.93|2645.86|11414.41|23.3|||| 794|DRG||NEONATE W OTHER SIGNIFICANT PROBLEMS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3,080.35|11414.41|11414.41|23.3|||| 794|DRG||NEONATE W OTHER SIGNIFICANT PROBLEMS|Blue Cross HMO Specialty|BCBSTX HMO|6,093.10|23.3|11414.41|23.3|||| 794|DRG||NEONATE W OTHER SIGNIFICANT PROBLEMS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|11,847.85|32.16|11414.41|23.3|||| 794|DRG||NEONATE W OTHER SIGNIFICANT PROBLEMS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|4,668.60|24.76|11414.41|23.3|||| 794|DRG||NEONATE W OTHER SIGNIFICANT PROBLEMS|Managed Medicaid|MEDICAID SUPERIOR|8,161.23|2549.72|11414.41|23.3|||| 794|DRG||NEONATE W OTHER SIGNIFICANT PROBLEMS|Managed Medicaid|MEDICAID AMERIGROUP|6,056.85|2549.72|11414.41|23.3|||| 795|DRG||NORMAL NEWBORN|Managed Medicaid|MEDICAID AMERIGROUP|4,558.98|1521.88|8084.85|8.24|||| 795|DRG||NORMAL NEWBORN|Managed Medicaid|MEDICAID SUPERIOR|4,496.35|1521.88|8084.85|8.24|||| 795|DRG||NORMAL NEWBORN|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|7,532.25|727.64|8084.85|8.24|||| 795|DRG||NORMAL NEWBORN|Cigna|CIGNA|4,418.60|11|8084.85|8.24|||| 795|DRG||NORMAL NEWBORN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|12,435.10|2549.72|8084.85|8.24|||| 795|DRG||NORMAL NEWBORN|Blue Cross HMO Specialty|BCBSTX HMO|4,784.18|649.46|8084.85|8.24|||| 795|DRG||NORMAL NEWBORN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3,024.60|3052.69|8084.85|8.24|||| 795|DRG||NORMAL NEWBORN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|4,496.35|3072.91|8084.85|8.24|||| 795|DRG||NORMAL NEWBORN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4,937.85|701.27|8084.85|8.24|||| 795|DRG||NORMAL NEWBORN|Blue Cross PPO Specialty|BCBSTX PPO|4,398.23|763.97|8084.85|8.24|||| 795|DRG||NORMAL NEWBORN|United Healthcare|UNITED HEALTHCARE OTHER|3,738.35|8.24|8084.85|8.24|||| 795|DRG||NORMAL NEWBORN|Tricare|TRICARE EAST REGION|6,008.85|717.27|8084.85|8.24|||| 795|DRG||NORMAL NEWBORN|NON CONTRACTED|COMMERCIAL OTHER 1|8,084.85|8084.85|8084.85|8.24|||| 795|DRG||NORMAL NEWBORN|United Healthcare|UNITED HEALTHCARE|5,647.35|16.48|8084.85|8.24|||| 795|DRG||NORMAL NEWBORN|Medicaid|MOLINA HEALTHCARE OF TEXAS|2,751.60|957.16|8084.85|8.24|||| 795|DRG||NORMAL NEWBORN|Medicaid|MEDICAID|4,418.60|957.16|8084.85|8.24|||| 798|DRG||VAGINAL DELIVERY W STERILIZATION/D&C W/O CC/MCC|Managed Medicaid|MEDICAID AMERIGROUP|37,864.90|9335.72|9335.72|9335.72|||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Managed Medicare|HEALTHSPRING MA|324.25||||324.25||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|324.25||||75.75||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Medicaid|COUNTY INDIGENT HEALTH OTHER|324.25||||||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Medicaid|MEDICAID TEXAS CHILDRENS|||||75.75||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Medicaid|MEDICAID|324.25||||324.25||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Medicaid|SUPERIOR HEALTHPLAN CHIP|324.25||||75.75||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Managed Medicaid|MEDICAID SUPERIOR|324.25||||324.25||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|324.25||||75.75||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Medicaid|MEDICAID HMO|||||324.25||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||324.25||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||324.25||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Medicare|MEDICARE ACUTE|324.25||||75.75||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Tricare|TRICARE EAST REGION|324.25||||324.25||| 80048|EAP|0300|BASIC METOBOLIC PANEL|NON CONTRACTED|COMMERCIAL OTHER 2|||||324.25||| 80048|EAP|0300|BASIC METOBOLIC PANEL|UTMB|UTMB CORRECTIONAL MANAGED CARE|324.25||||324.25||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Rusk State Hospital|RUSK STATE HOSP|324.25||||2.00||| 80048|EAP|0300|BASIC METOBOLIC PANEL|NON CONTRACTED|COMMERCIAL OTHER 1|324.25||||324.25||| 80048|EAP|0300|BASIC METOBOLIC PANEL|United Healthcare|UNITED HEALTHCARE OTHER|324.25||||75.75||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Workers Compensation|WORKERS COMPENSATION OTHER|324.25||||324.25||| 80048|EAP|0300|BASIC METOBOLIC PANEL|United Medicare Advantage|UHC MEDICARE GOLD MA|324.25||||75.75||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Workers Compensation|UT EMPLOYEE INJURY|324.25||||324.25||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Medicare|MEDICARE PART B ONLY IP|324.25||||||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|324.25||||||| 80048|EAP|0300|BASIC METOBOLIC PANEL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|324.25||||75.75||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Managed Medicaid|MEDICAID AMERIGROUP|324.25||||324.25||| 80048|EAP|0300|BASIC METOBOLIC PANEL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|324.25||||75.75||| 80048|EAP|0300|BASIC METOBOLIC PANEL|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|324.25||||75.75||| 80048|EAP|0300|BASIC METOBOLIC PANEL|United Healthcare|UMR UNITED MEDICAL RESOURCES|324.25||||324.25||| 80048|EAP|0300|BASIC METOBOLIC PANEL|United Healthcare|TML GROUP BENEFITS|324.25||||75.75||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|324.25||||75.75||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Veterans Affairs|VETERANS ADMINISTRATION|324.25||||2.00||| 80048|EAP|0300|BASIC METOBOLIC PANEL|United Healthcare|UNITED HEALTHCARE|324.25||||324.25||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|324.25||||324.25||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Aetna|AETNA OTHER|324.25||||||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|324.25||||75.75||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Aetna|AETNA PPO|324.25||||2.00||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Aenta Medicare Advantage|AETNA MEDICARE MA|324.25||||324.25||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|324.25||||324.25||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|324.25||||||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Blue Cross HMO Specialty|BCBSTX HMO|324.25||||324.25||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Blue Cross PPO Specialty|BCBSTX PPO|324.25||||324.25||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Cigna|CIGNA|||||324.25||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Cigna|CIGNA|324.25||||||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Blue Cross PPO Specialty|BCBSTX OTHER|324.25||||324.25||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Humana Medicare Advantage|HUMANA MA|324.25||||75.75||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Brinson Benefits|THE HEALTH PLAN SMITH CO|324.25||||||| 80048|EAP|0300|BASIC METOBOLIC PANEL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|324.25||||75.75||| 80051|EAP|0300|ELECTROLYTES 4 TESTS|Humana Medicare Advantage|HUMANA MA|||||62.75||| 80051|EAP|0300|ELECTROLYTES 4 TESTS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||268.75||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||94.50||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|NON CONTRACTED|COMMERCIAL OTHER 2|405.25||||405.25||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|NON CONTRACTED|COMMERCIAL OTHER 1|405.25||||94.50||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|PHCS|HUMANA INSURANCE|||||94.50||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Medicare|MEDICARE PART B ONLY IP|405.25||||94.50||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Tricare|TRICARE EAST REGION|405.25||||94.50||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Rusk State Hospital|RUSK STATE HOSP|405.25||||405.25||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||405.25||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Managed Medicare|HEALTHSPRING MA|405.25||||94.50||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Managed Medicaid|MEDICAID AMERIGROUP|405.25||||94.50||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Medicaid|MEDICAID|405.25||||405.25||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Managed Medicare|HOSPICE OF EAST TEXAS|405.25||||94.50||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|405.25||||94.50||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Managed Medicaid|MEDICAID UNITED HEALTHCARE|405.25||||94.50||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Managed Medicaid|MEDICAID SUPERIOR|405.25||||94.50||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Medicaid|COUNTY INDIGENT HEALTH OTHER|405.25||||249.88||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Medicaid|MOLINA HEALTHCARE OF TEXAS|405.25||||94.50||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Medicaid|SUPERIOR HEALTHPLAN CHIP|405.25||||94.50||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|405.25||||94.50||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Managed Medicare|BCBS MEDICARE PPO MA|||||94.50||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Workers Compensation|UT EMPLOYEE INJURY|405.25||||||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|United Medicare Advantage|AARP UHC WEST COMPLETE MA|405.25||||94.50||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|405.25||||94.50||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|United Medicare Advantage|UHC MEDICARE GOLD MA|405.25||||94.50||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|405.25||||94.50||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Medicaid|MEDICAID HMO|||||94.50||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|United Healthcare|UNITED HEALTHCARE OTHER|405.25||||94.50||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|United Healthcare|UMR UNITED MEDICAL RESOURCES|405.25||||94.50||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|United Healthcare|TML GROUP BENEFITS|405.25||||94.50||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|United Healthcare|GEHA|||||249.88||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Medicaid|MEDICAID PCCM|||||405.25||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|United Healthcare|AARP|||||94.50||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Veterans Affairs|VETERANS ADMINISTRATION|405.25||||405.25||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|United Healthcare|GOLDEN RULE|||||94.50||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Workers Compensation|WORKERS COMPENSATION OTHER|405.25||||405.25||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Medicaid|MEDICAID TEXAS CHILDRENS|||||94.50||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|405.25||||249.88||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|United Healthcare|UNITED HEALTHCARE|405.25||||94.50||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|405.25||||94.50||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|405.25||||94.50||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Aetna|AETNA OTHER|405.25||||94.50||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Blue Cross HMO Specialty|BCBSTX HMO|405.25||||94.50||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Access Direct Platinum|HEALTHFIRST TPA UMR|||||94.50||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Aenta Medicare Advantage|AETNA MEDICARE MA|405.25||||94.50||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Aetna|BOON CHAPMAN|||||94.50||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|405.25||||94.50||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Aetna|AETNA PPO|405.25||||94.50||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||94.50||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|UTMB|UTMB CORRECTIONAL MANAGED CARE|405.25||||405.25||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Medicare|MEDICARE ACUTE|405.25||||94.50||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Brinson Benefits|THE HEALTH PLAN SMITH CO|405.25||||||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Humana Medicare Advantage|HUMANA MA|405.25||||94.50||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Blue Cross PPO Specialty|BCBSTX PPO|405.25||||94.50||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Cigna|CIGNA|405.25||||94.50||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Cigna|CIGNA|405.25||||||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Cigna|CIGNA|||||94.50||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Blue Cross PPO Specialty|BCBSTX OTHER|405.25||||94.50||| 80053|EAP|0300|COMPREHENSIVE METOBOLIC P|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|405.25||||94.50||| 80061|EAP|0301|LIPID PANEL I|Humana Medicare Advantage|HUMANA MA|513.50||||119.75||| 80061|EAP|0301|LIPID PANEL I|Blue Cross PPO Specialty|BCBSTX OTHER|||||119.75||| 80061|EAP|0301|LIPID PANEL I|Cigna|CIGNA|||||119.75||| 80061|EAP|0301|LIPID PANEL I|Blue Cross PPO Specialty|BCBSTX PPO|||||119.75||| 80061|EAP|0301|LIPID PANEL I|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||119.75||| 80061|EAP|0301|LIPID PANEL I|Aenta Medicare Advantage|AETNA MEDICARE MA|||||119.75||| 80061|EAP|0301|LIPID PANEL I|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||119.75||| 80061|EAP|0301|LIPID PANEL I|Aetna|BOON CHAPMAN|||||119.75||| 80061|EAP|0301|LIPID PANEL I|Aetna|AETNA PPO|||||119.75||| 80061|EAP|0301|LIPID PANEL I|Blue Cross HMO Specialty|BCBSTX HMO|||||119.75||| 80061|EAP|0301|LIPID PANEL I|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||119.75||| 80061|EAP|0301|LIPID PANEL I|United Healthcare|UNITED HEALTHCARE OTHER|||||119.75||| 80061|EAP|0301|LIPID PANEL I|United Healthcare|TML GROUP BENEFITS|||||119.75||| 80061|EAP|0301|LIPID PANEL I|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||119.75||| 80061|EAP|0301|LIPID PANEL I|United Healthcare|GEHA|||||119.75||| 80061|EAP|0301|LIPID PANEL I|Workers Compensation|WORKERS COMPENSATION OTHER|||||119.75||| 80061|EAP|0301|LIPID PANEL I|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|513.50||||119.75||| 80061|EAP|0301|LIPID PANEL I|United Healthcare|AARP|||||119.75||| 80061|EAP|0301|LIPID PANEL I|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||119.75||| 80061|EAP|0301|LIPID PANEL I|United Medicare Advantage|AARP UHC WEST COMPLETE MA|513.50||||119.75||| 80061|EAP|0301|LIPID PANEL I|United Medicare Advantage|UHC MEDICARE GOLD MA|513.50||||119.75||| 80061|EAP|0301|LIPID PANEL I|Veterans Affairs|VETERANS ADMINISTRATION|||||119.75||| 80061|EAP|0301|LIPID PANEL I|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|513.50||||119.75||| 80061|EAP|0301|LIPID PANEL I|United Healthcare|UNITED HEALTHCARE|||||119.75||| 80061|EAP|0301|LIPID PANEL I|Medicaid|MEDICAID|513.50||||119.75||| 80061|EAP|0301|LIPID PANEL I|Managed Medicaid|MEDICAID SUPERIOR|||||119.75||| 80061|EAP|0301|LIPID PANEL I|Medicaid|SUPERIOR HEALTHPLAN CHIP|513.50||||119.75||| 80061|EAP|0301|LIPID PANEL I|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||119.75||| 80061|EAP|0301|LIPID PANEL I|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||119.75||| 80061|EAP|0301|LIPID PANEL I|Managed Medicare|BCBS MEDICARE PPO MA|||||119.75||| 80061|EAP|0301|LIPID PANEL I|Medicaid|MEDICAID HMO|||||119.75||| 80061|EAP|0301|LIPID PANEL I|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|513.50||||119.75||| 80061|EAP|0301|LIPID PANEL I|Aetna|AETNA OTHER|||||119.75||| 80061|EAP|0301|LIPID PANEL I|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||119.75||| 80061|EAP|0301|LIPID PANEL I|Managed Medicare|HEALTHSPRING MA|||||119.75||| 80061|EAP|0301|LIPID PANEL I|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||119.75||| 80061|EAP|0301|LIPID PANEL I|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||119.75||| 80061|EAP|0301|LIPID PANEL I|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||119.75||| 80061|EAP|0301|LIPID PANEL I|Managed Medicaid|MEDICAID AMERIGROUP|513.50||||119.75||| 80061|EAP|0301|LIPID PANEL I|Medicaid|MEDICAID TEXAS CHILDRENS|||||119.75||| 80061|EAP|0301|LIPID PANEL I|Medicaid|MEDICAID PCCM|||||119.75||| 80061|EAP|0301|LIPID PANEL I|Tricare|TRICARE EAST REGION|||||119.75||| 80061|EAP|0301|LIPID PANEL I|UTMB|UTMB CORRECTIONAL MANAGED CARE|513.50||||||| 80061|EAP|0301|LIPID PANEL I|Medicare|MEDICARE ACUTE|513.50||||119.75||| 80061|EAP|0301|LIPID PANEL I|PHCS|HUMANA INSURANCE|||||119.75||| 80061|EAP|0301|LIPID PANEL I|NON CONTRACTED|COMMERCIAL OTHER 1|||||119.75||| 80061|EAP|0301|LIPID PANEL I|Medicare|MEDICARE PART B ONLY IP|513.50||||119.75||| 80061|EAP|0301|LIPID PANEL I|Rusk State Hospital|RUSK STATE HOSP|||||119.75||| 80069|EAP|0300|RENAL FUNCTION PANEL|Tricare|TRICARE EAST REGION|||||695.75||| 80069|EAP|0300|RENAL FUNCTION PANEL|Medicare|MEDICARE PART B ONLY IP|695.75||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|Medicare|MEDICARE ACUTE|695.75||||695.75||| 80069|EAP|0300|RENAL FUNCTION PANEL|NON CONTRACTED|COMMERCIAL OTHER 1|695.75||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|Medicaid|MEDICAID|695.75||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||695.75||| 80069|EAP|0300|RENAL FUNCTION PANEL|Managed Medicare|BCBS MEDICARE PPO MA|||||695.75||| 80069|EAP|0300|RENAL FUNCTION PANEL|Managed Medicaid|MEDICAID AMERIGROUP|695.75||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|695.75||||695.75||| 80069|EAP|0300|RENAL FUNCTION PANEL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|695.75||||695.75||| 80069|EAP|0300|RENAL FUNCTION PANEL|Managed Medicaid|MEDICAID SUPERIOR|695.75||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|Medicaid|MEDICAID TEXAS CHILDRENS|||||695.75||| 80069|EAP|0300|RENAL FUNCTION PANEL|Medicaid|MEDICAID HMO|||||695.75||| 80069|EAP|0300|RENAL FUNCTION PANEL|Managed Medicare|HEALTHSPRING MA|695.75||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|UTMB|UTMB CORRECTIONAL MANAGED CARE|695.75||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|United Medicare Advantage|UHC MEDICARE GOLD MA|695.75||||695.75||| 80069|EAP|0300|RENAL FUNCTION PANEL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||695.75||| 80069|EAP|0300|RENAL FUNCTION PANEL|United Healthcare|UMR UNITED MEDICAL RESOURCES|695.75||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|695.75||||695.75||| 80069|EAP|0300|RENAL FUNCTION PANEL|Veterans Affairs|VETERANS ADMINISTRATION|695.75||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|695.75||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|Aenta Medicare Advantage|AETNA MEDICARE MA|695.75||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|Aetna|AETNA OTHER|695.75||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|695.75||||||| 80069|EAP|0300|RENAL FUNCTION PANEL|Cigna|CIGNA|||||695.75||| 80069|EAP|0300|RENAL FUNCTION PANEL|Humana Medicare Advantage|HUMANA MA|695.75||||695.75||| 80069|EAP|0300|RENAL FUNCTION PANEL|Blue Cross PPO Specialty|BCBSTX PPO|695.75||||695.75||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||0.73||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.73||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Cigna|CIGNA|||||0.73||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Humana Medicare Advantage|HUMANA MA|3.13||||0.73||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Blue Cross HMO Specialty|BCBSTX HMO|||||0.73||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Aetna|AETNA PPO|||||0.73||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Aenta Medicare Advantage|AETNA MEDICARE MA|||||0.73||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.73||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Aetna|AETNA OTHER|||||0.73||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.73||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Workers Compensation|UT EMPLOYEE INJURY|||||3.13||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.73||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.73||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||0.73||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|United Healthcare|UNITED HEALTHCARE|||||0.73||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Blue Cross PPO Specialty|BCBSTX PPO|||||0.73||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Medicaid|MEDICAID TEXAS CHILDRENS|||||0.73||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Medicaid|MEDICAID|3.13||||0.73||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.73||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Managed Medicaid|MEDICAID SUPERIOR|||||0.73||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.73||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Managed Medicaid|MEDICAID AMERIGROUP|||||0.73||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.73||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|NON CONTRACTED|COMMERCIAL OTHER 1|3.13||||0.73||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Medicare|MEDICARE ACUTE|3.13||||0.73||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.13||||||| 80076|EAP|0300|HEPATIC FUNCTION PANEL|Tricare|TRICARE EAST REGION|||||0.73||| 80101|EAP|0300||Managed Medicaid|MEDICAID SUPERIOR|||||1.18||| 80101|EAP|0300|DRUG SCREEN & ALCOHOL,URI|Workers Compensation|WORKERS COMPENSATION OTHER|||||527.75||| 80101|EAP|0300|DRUG SCREEN & ALCOHOL,URI|Workers Compensation|UT EMPLOYEE INJURY|||||1.23||| 80156|EAP|0300|CARBAMAZEPINE (TEGRETOL)|Humana Medicare Advantage|HUMANA MA|||||1.30||| 80156|EAP|0300|CARBAMAZEPINE (TEGRETOL)|Rusk State Hospital|RUSK STATE HOSP|5.58||||||| 80156|EAP|0300|CARBAMAZEPINE (TEGRETOL)|Medicare|MEDICARE ACUTE|||||5.58||| 80156|EAP|0300|CARBAMAZEPINE (TEGRETOL)|UTMB|UTMB CORRECTIONAL MANAGED CARE|5.58||||5.58||| 80158|EAP|0301|CYCLOSPORINE|Tricare|TRICARE EAST REGION|||||161.25||| 80162|EAP|0300|DIGOXIN|United Medicare Advantage|UHC MEDICARE GOLD MA|||||118.75||| 80162|EAP|0300|DIGOXIN|Veterans Affairs|VETERANS ADMINISTRATION|508.50||||||| 80162|EAP|0300|DIGOXIN|United Medicare Advantage|AARP UHC WEST COMPLETE MA|508.50||||||| 80162|EAP|0300|DIGOXIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|508.50||||508.50||| 80162|EAP|0300|DIGOXIN|Aenta Medicare Advantage|AETNA MEDICARE MA|508.50||||||| 80162|EAP|0300|DIGOXIN|Humana Medicare Advantage|HUMANA MA|508.50||||118.75||| 80162|EAP|0300|DIGOXIN|Medicaid|COUNTY INDIGENT HEALTH OTHER|508.50||||||| 80162|EAP|0300|DIGOXIN|Managed Medicare|HOSPICE OF EAST TEXAS|||||118.75||| 80162|EAP|0300|DIGOXIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||118.75||| 80162|EAP|0300|DIGOXIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||118.75||| 80162|EAP|0300|DIGOXIN|Medicare|MEDICARE ACUTE|508.50||||118.75||| 80162|EAP|0300|DIGOXIN|NON CONTRACTED|COMMERCIAL OTHER 1|508.50||||||| 80162|EAP|0300|DIGOXIN|UTMB|UTMB CORRECTIONAL MANAGED CARE|508.50||||508.50||| 80165|EAP|0300|VALPORIC ACID|UTMB|UTMB CORRECTIONAL MANAGED CARE|519.25||||519.25||| 80165|EAP|0300|VALPORIC ACID|Medicare|MEDICARE ACUTE|519.25||||519.25||| 80165|EAP|0300|VALPORIC ACID|Rusk State Hospital|RUSK STATE HOSP|519.25||||320.13||| 80165|EAP|0300|VALPORIC ACID|Medicaid|MEDICAID|519.25||||320.13||| 80165|EAP|0300|VALPORIC ACID|Managed Medicaid|MEDICAID SUPERIOR|||||1.21||| 80165|EAP|0300|VALPORIC ACID|Managed Medicaid|MEDICAID UNITED HEALTHCARE|519.25||||519.25||| 80165|EAP|0300|VALPORIC ACID|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1.21||| 80165|EAP|0300|VALPORIC ACID|Blue Cross PPO Specialty|BCBSTX PPO|||||1.21||| 80165|EAP|0300|VALPORIC ACID|Humana Medicare Advantage|HUMANA MA|519.25||||519.25||| 80165|EAP|0300|VALPORIC ACID|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1.21||| 80165|EAP|0300|VALPORIC ACID|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.21||| 80170|EAP|0301|GENTAMYCIN TROUGH|Managed Medicaid|MEDICAID AMERIGROUP|6.28||||||| 80170|EAP|0300|GENTAMYCIN PEAK|Managed Medicaid|MEDICAID AMERIGROUP|6.28||||||| 80175|EAP|0301|LAMOTRIGINE (LAMICTAL)|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||122.25||| 80175|EAP|0301|LAMOTRIGINE (LAMICTAL)|Blue Cross PPO Specialty|BCBSTX PPO|||||122.25||| 80175|EAP|0301|LAMOTRIGINE (LAMICTAL)|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||122.25||| 80175|EAP|0301|LAMOTRIGINE (LAMICTAL)|Medicaid|MEDICAID HMO|||||485.75||| 80177|EAP|0301|KEPPRA LEVETIRACETIM DRUG|Medicare|MEDICARE ACUTE|||||161.25||| 80177|EAP|0301|KEPPRA LEVETIRACETIM DRUG|UTMB|UTMB CORRECTIONAL MANAGED CARE|691.50||||691.50||| 80177|EAP|0301|KEPPRA LEVETIRACETIM DRUG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||161.25||| 80177|EAP|0301|KEPPRA LEVETIRACETIM DRUG|Managed Medicaid|MEDICAID SUPERIOR|691.50||||161.25||| 80177|EAP|0301|KEPPRA LEVETIRACETIM DRUG|Blue Cross HMO Specialty|BCBSTX HMO|691.50||||||| 80177|EAP|0301|KEPPRA LEVETIRACETIM DRUG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||161.25||| 80177|EAP|0301|KEPPRA LEVETIRACETIM DRUG|Blue Cross PPO Specialty|BCBSTX PPO|691.50||||161.25||| 80177|EAP|0301|KEPPRA LEVETIRACETIM DRUG|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||161.25||| 80177|EAP|0301|KEPPRA LEVETIRACETIM DRUG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||691.50||| 80178|EAP|0300|LITHIUM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.59||| 80178|EAP|0300|LITHIUM|United Medicare Advantage|UHC MEDICARE GOLD MA|||||253.25||| 80178|EAP|0300|LITHIUM|United Healthcare|UMR UNITED MEDICAL RESOURCES|253.25||||0.59||| 80178|EAP|0300|LITHIUM|Blue Cross PPO Specialty|BCBSTX PPO|||||253.25||| 80178|EAP|0300|LITHIUM|Aetna|AETNA PPO|||||0.59||| 80178|EAP|0300|LITHIUM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||156.13||| 80178|EAP|0300|LITHIUM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|253.25||||0.59||| 80178|EAP|0300|LITHIUM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.59||| 80178|EAP|0300|LITHIUM|Medicare|MEDICARE ACUTE|253.25||||156.13||| 80178|EAP|0300|LITHIUM|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||253.25||| 80185|EAP|0300|PHENYTOIN TOTAL|NON CONTRACTED|COMMERCIAL OTHER 1|||||5.08||| 80185|EAP|0300|PHENYTOIN TOTAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|5.08||||5.08||| 80185|EAP|0300|PHENYTOIN TOTAL|Medicare|MEDICARE ACUTE|5.08||||118.50||| 80185|EAP|0300|PHENYTOIN TOTAL|Rusk State Hospital|RUSK STATE HOSP|||||5.08||| 80185|EAP|0300|PHENYTOIN TOTAL|Managed Medicare|HEALTHSPRING MA|||||118.50||| 80185|EAP|0300|PHENYTOIN TOTAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||118.50||| 80185|EAP|0300|PHENYTOIN TOTAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||118.50||| 80185|EAP|0300|PHENYTOIN TOTAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||118.50||| 80185|EAP|0300|PHENYTOIN TOTAL|Blue Cross PPO Specialty|BCBSTX PPO|5.08||||5.08||| 80185|EAP|0300|PHENYTOIN TOTAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.08||||313.25||| 80185|EAP|0300|PHENYTOIN TOTAL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||118.50||| 80186|EAP|0300|PHENYTOIN, FREE|Medicare|MEDICARE ACUTE|||||1.23||| 80197|EAP|0300|PROGRAF/TACROLIMUS|Blue Cross HMO Specialty|BCBSTX HMO|525.75||||122.75||| 80197|EAP|0300|PROGRAF/TACROLIMUS|Cigna|CIGNA|||||122.75||| 80197|EAP|0300|PROGRAF/TACROLIMUS|Medicaid|MEDICAID TEXAS CHILDRENS|||||122.75||| 80197|EAP|0300|PROGRAF/TACROLIMUS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||122.75||| 80197|EAP|0300|PROGRAF/TACROLIMUS|Medicare|MEDICARE ACUTE|||||122.75||| 80198|EAP|0300|THEOPHYLLINE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.42||||||| 80198|EAP|0300|THEOPHYLLINE|Veterans Affairs|VETERANS ADMINISTRATION|5.42||||||| 80201|EAP|0301|TOPIRAMATE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||106.50||| 80202|EAP|0300|VANCOMYCIN TROUGH|Medicare|MEDICARE ACUTE|519.25||||1.21||| 80202|EAP|0300|VANCOMYCIN TROUGH|UTMB|UTMB CORRECTIONAL MANAGED CARE|519.25||||||| 80202|EAP|0300|VANCOMYCIN PEAK|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|519.25||||1.21||| 80202|EAP|0300|VANCOMYCIN TROUGH|Managed Medicaid|MEDICAID SUPERIOR|519.25||||||| 80202|EAP|0300|VANCOMYCIN TROUGH|Managed Medicare|HEALTHSPRING MA|519.25||||||| 80202|EAP|0300|VANCOMYCIN TROUGH|Managed Medicaid|MEDICAID UNITED HEALTHCARE|519.25||||1.21||| 80202|EAP|0300|VANCOMYCIN TROUGH|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|519.25||||||| 80202|EAP|0300|VANCOMYCIN TROUGH|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|519.25||||1.21||| 80202|EAP|0300|VANCOMYCIN TROUGH|Medicaid|MEDICAID|519.25||||||| 80202|EAP|0300|VANCOMYCIN TROUGH|United Medicare Advantage|UHC MEDICARE GOLD MA|519.25||||1.21||| 80202|EAP|0300|VANCOMYCIN TROUGH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|519.25||||1.21||| 80202|EAP|0300|VANCOMYCIN PEAK|Blue Cross PPO Specialty|BCBSTX PPO|||||519.25||| 80202|EAP|0300|VANCOMYCIN TROUGH|Humana Medicare Advantage|HUMANA MA|519.25||||||| 80202|EAP|0300|VANCOMYCIN TROUGH|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|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|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|519.25||||||| 80202|EAP|0300|VANCOMYCIN TROUGH|Aetna|AETNA PPO|519.25||||||| 80280|EAP|0300|DRUG ASSAY VEDOLIZUMAB|Tricare|TRICARE EAST REGION|||||115.71||| 80299|EAP|0300|LACOSAMIDE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||117.50||| 80299|EAP|0300|LACOSAMIDE|Medicare|MEDICARE ACUTE|||||117.50||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Aenta Medicare Advantage|AETNA MEDICARE MA|527.75||||527.75||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Blue Cross HMO Specialty|BCBSTX HMO|527.75||||1.23||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||325.38||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Aetna|AETNA OTHER|||||527.75||| 80307|EAP|0300|METHAMPHETAMINE CONFIRMAT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|193.75||||||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|527.75||||325.38||| 80307|EAP|0300|DRUG SCREEN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.26||||||| 80307|EAP|0300|DRUG SCREEN 10|Humana Medicare Advantage|HUMANA MA|||||1.23||| 80307|EAP|0300|BENZODIAZEPINE GCMS|Blue Cross PPO Specialty|BCBSTX PPO|||||134.50||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Cigna|CIGNA|||||527.75||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Cigna|CIGNA|527.75||||1.23||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Humana Medicare Advantage|HUMANA MA|527.75||||527.75||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Blue Cross PPO Specialty|BCBSTX OTHER|||||527.75||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Blue Cross PPO Specialty|BCBSTX PPO|527.75||||1.23||| 80307|EAP|0300|DRUG SCREEN 10|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.23||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|United Healthcare|UNITED HEALTHCARE OTHER|527.75||||527.75||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|United Healthcare|UNITED HEALTHCARE|||||527.75||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|527.75||||527.75||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||527.75||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|United Healthcare|UNITED HEALTHCARE|527.75||||||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|United Medicare Advantage|AARP UHC WEST COMPLETE MA|527.75||||325.38||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Veterans Affairs|VETERANS ADMINISTRATION|||||527.75||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|United Medicare Advantage|UHC MEDICARE GOLD MA|527.75||||325.38||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Workers Compensation|WORKERS COMPENSATION OTHER|||||527.75||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|United Healthcare|UMR UNITED MEDICAL RESOURCES|527.75||||527.75||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Tricare|TRICARE EAST REGION|||||1.23||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Rusk State Hospital|RUSK STATE HOSP|527.75||||1.23||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Medicare|MEDICARE ACUTE|527.75||||527.75||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|UTMB|UTMB CORRECTIONAL MANAGED CARE|527.75||||527.75||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Workers Compensation|UT EMPLOYEE INJURY|||||527.75||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|NON CONTRACTED|COMMERCIAL OTHER 1|||||1.23||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|NON CONTRACTED|COMMERCIAL OTHER 2|||||527.75||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||1.23||| 80307|EAP|0300|DRUG SCREEN|Medicaid|MEDICAID|4.26||||||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||527.75||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||527.75||| 80307|EAP|0300|DRUG SCREEN 10|Managed Medicaid|MEDICAID SUPERIOR|4.26||||1.23||| 80307|EAP|0300|DRUG SCREEN|Managed Medicaid|MEDICAID SUPERIOR|4.26||||1.18||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.23||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Aetna|AETNA PPO|527.75||||1.23||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Medicaid|MEDICAID|527.75||||1.23||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Managed Medicaid|MEDICAID SUPERIOR|527.75||||1.23||| 80307|EAP|0301|OPIATE GCMS|Managed Medicaid|MEDICAID AMERIGROUP|507.50||||1.23||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||527.75||| 80307|EAP|0301|OPIATE GCMS|Managed Medicaid|MEDICAID SUPERIOR|507.50||||1.23||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||1.23||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Medicaid|MEDICAID TEXAS CHILDRENS|||||527.75||| 80307|EAP|0300|DRUG SCREEN 10|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.26||||1.23||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||527.75||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Managed Medicaid|MEDICAID AMERIGROUP|527.75||||1.23||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Medicaid|MEDICAID PCCM|||||527.75||| 80307|EAP|0300|DRUG SCREEN|Managed Medicaid|MEDICAID AMERIGROUP|4.26||||||| 80307|EAP|0301|DRUG SCREEN MEDICAL IN HO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|527.75||||1.23||| 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|Medicaid|MEDICAID HMO|||||527.75||| 80320|EAP|0301|ALCOHOL|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||4.14||| 80320|EAP|0301|ALCOHOL|Medicaid|MEDICAID|||||4.14||| 80320|EAP|0301|ALCOHOL|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||4.14||| 80320|EAP|0301|ALCOHOL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.14||||4.14||| 80320|EAP|0301|ALCOHOL|Managed Medicaid|MEDICAID SUPERIOR|||||4.14||| 80320|EAP|0301|ALCOHOL|Managed Medicaid|MEDICAID AMERIGROUP|||||4.14||| 80320|EAP|0301|ALCOHOL|Rusk State Hospital|RUSK STATE HOSP|||||4.14||| 80320|EAP|0301|ALCOHOL|Medicare|MEDICARE ACUTE|4.14||||4.14||| 80320|EAP|0301|ALCOHOL|NON CONTRACTED|COMMERCIAL OTHER 1|||||96.50||| 80320|EAP|0301|ALCOHOL|UTMB|UTMB CORRECTIONAL MANAGED CARE|4.14||||4.14||| 80320|EAP|0301|ALCOHOL|Medicare|MEDICARE PART B ONLY IP|4.14||||||| 80320|EAP|0301|ALCOHOL|United Medicare Advantage|UHC MEDICARE GOLD MA|4.14||||4.14||| 80320|EAP|0301|ALCOHOL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.14||||4.14||| 80320|EAP|0301|ALCOHOL|United Healthcare|UNITED HEALTHCARE|4.14||||||| 80320|EAP|0301|ALCOHOL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4.14||||4.14||| 80320|EAP|0301|ALCOHOL|Medicaid|MEDICAID TEXAS CHILDRENS|||||4.14||| 80320|EAP|0301|ALCOHOL|United Healthcare|UNITED HEALTHCARE OTHER|||||4.14||| 80320|EAP|0301|ALCOHOL|Workers Compensation|UT EMPLOYEE INJURY|||||4.14||| 80320|EAP|0301|ALCOHOL|Veterans Affairs|VETERANS ADMINISTRATION|||||4.14||| 80320|EAP|0301|ALCOHOL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|4.14||||4.14||| 80320|EAP|0301|ALCOHOL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||4.14||| 80320|EAP|0301|ALCOHOL|Blue Cross PPO Specialty|BCBSTX PPO|4.14||||4.14||| 80320|EAP|0301|ALCOHOL|Humana Medicare Advantage|HUMANA MA|4.14||||4.14||| 80320|EAP|0301|ALCOHOL|Cigna|CIGNA|||||4.14||| 80320|EAP|0301|ALCOHOL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||4.14||| 80320|EAP|0301|ALCOHOL|Aetna|AETNA PPO|||||4.14||| 80320|EAP|0301|ALCOHOL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||4.14||| 80320|EAP|0301|ALCOHOL|Aenta Medicare Advantage|AETNA MEDICARE MA|4.14||||||| 80320|EAP|0301|ALCOHOL|Blue Cross HMO Specialty|BCBSTX HMO|||||4.14||| 80325|EAP|0300|AMPHETAMINE GCMS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|409.50||||||| 80325|EAP|0300|AMPHETAMINE GCMS|Managed Medicaid|MEDICAID SUPERIOR|409.50||||||| 80325|EAP|0300|AMPHETAMINE GCMS|Managed Medicaid|MEDICAID AMERIGROUP|409.50||||||| 80329|EAP|0301|ACETAMINOPHEN|Medicare|MEDICARE ACUTE|775.25||||775.25||| 80329|EAP|0301|ACETAMINOPHEN|UTMB|UTMB CORRECTIONAL MANAGED CARE|775.25||||775.25||| 80329|EAP|0300|SALICYLATES|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.72||||2.72||| 80329|EAP|0300|SALICYLATES|Rusk State Hospital|RUSK STATE HOSP|||||2.72||| 80329|EAP|0300|SALICYLATES|Medicare|MEDICARE ACUTE|||||2.72||| 80329|EAP|0301|ACETAMINOPHEN|Rusk State Hospital|RUSK STATE HOSP|||||775.25||| 80329|EAP|0301|ACETAMINOPHEN|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||775.25||| 80329|EAP|0300|SALICYLATES|Managed Medicaid|MEDICAID SUPERIOR|||||2.72||| 80329|EAP|0300|SALICYLATES|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.72||||2.72||| 80329|EAP|0301|ACETAMINOPHEN|Managed Medicaid|MEDICAID AMERIGROUP|||||775.25||| 80329|EAP|0301|ACETAMINOPHEN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||775.25||| 80329|EAP|0301|ACETAMINOPHEN|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||775.25||| 80329|EAP|0301|ACETAMINOPHEN|Medicaid|MEDICAID|||||775.25||| 80329|EAP|0300|SALICYLATES|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||2.72||| 80329|EAP|0300|SALICYLATES|Managed Medicaid|MEDICAID AMERIGROUP|||||2.72||| 80329|EAP|0300|SALICYLATES|Medicaid|MEDICAID|||||2.72||| 80329|EAP|0301|ACETAMINOPHEN|Managed Medicare|HEALTHSPRING MA|775.25||||||| 80329|EAP|0301|ACETAMINOPHEN|Managed Medicaid|MEDICAID SUPERIOR|||||775.25||| 80329|EAP|0301|ACETAMINOPHEN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|775.25||||775.25||| 80329|EAP|0301|ACETAMINOPHEN|Medicaid|MEDICAID TEXAS CHILDRENS|||||775.25||| 80329|EAP|0301|ACETAMINOPHEN|United Medicare Advantage|UHC MEDICARE GOLD MA|775.25||||775.25||| 80329|EAP|0300|SALICYLATES|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.72||||||| 80329|EAP|0300|SALICYLATES|Medicaid|MEDICAID TEXAS CHILDRENS|||||2.72||| 80329|EAP|0300|SALICYLATES|United Medicare Advantage|UHC MEDICARE GOLD MA|||||2.72||| 80329|EAP|0301|ACETAMINOPHEN|United Healthcare|UNITED HEALTHCARE OTHER|||||775.25||| 80329|EAP|0301|ACETAMINOPHEN|United Healthcare|UNITED HEALTHCARE|775.25||||||| 80329|EAP|0300|SALICYLATES|United Healthcare|UNITED HEALTHCARE OTHER|||||2.72||| 80329|EAP|0301|ACETAMINOPHEN|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||775.25||| 80329|EAP|0300|SALICYLATES|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||2.72||| 80329|EAP|0301|ACETAMINOPHEN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|775.25||||||| 80329|EAP|0300|SALICYLATES|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2.72||| 80329|EAP|0301|ACETAMINOPHEN|Blue Cross PPO Specialty|BCBSTX PPO|775.25||||775.25||| 80329|EAP|0300|SALICYLATES|Blue Cross PPO Specialty|BCBSTX PPO|2.72||||2.72||| 80329|EAP|0301|ACETAMINOPHEN|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||775.25||| 80329|EAP|0300|SALICYLATES|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.72||| 80329|EAP|0301|ACETAMINOPHEN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||775.25||| 80329|EAP|0300|SALICYLATES|Blue Cross HMO Specialty|BCBSTX HMO|||||2.72||| 80329|EAP|0301|ACETAMINOPHEN|Blue Cross HMO Specialty|BCBSTX HMO|||||775.25||| 80345|EAP|0300|PHENOBARBITAL|Medicare|MEDICARE ACUTE|||||4.39||| 80349|EAP|0300|THC GCMS|Medicaid|MEDICAID|206.50||||||| 80349|EAP|0300|THC GCMS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|206.50||||||| 80349|EAP|0300|THC GCMS|Managed Medicaid|MEDICAID AMERIGROUP|206.50||||||| 80349|EAP|0300|THC GCMS|Managed Medicaid|MEDICAID SUPERIOR|206.50||||||| 80355|EAP|0300|NEURONTIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||117.50||| 80358|EAP|0300|METHADONE QNT|Managed Medicaid|MEDICAID SUPERIOR|625.75||||||| 80375|EAP|0301|TRILIPTAL DRUG LEVEL(OXCA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||122.25||| 80375|EAP|0301|TRILIPTAL DRUG LEVEL(OXCA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||122.25||| 80375|EAP|0301|TRILIPTAL DRUG LEVEL(OXCA|Aenta Medicare Advantage|AETNA MEDICARE MA|||||122.25||| 80375|EAP|0301|TRILIPTAL DRUG LEVEL(OXCA|Medicare|MEDICARE ACUTE|||||122.25||| 80375|EAP|0301|TRILIPTAL DRUG LEVEL(OXCA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||122.25||| 805|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W MCC|Medicaid|MEDICAID|38,492.55|7799.63|7799.63|7799.63|||| 806|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|27,664.50|8237.19|8237.19|51.79|||| 806|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W CC|Managed Medicaid|MEDICAID SUPERIOR|28,783.75|7805.25|8237.19|51.79|||| 806|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W CC|Managed Medicaid|MEDICAID AMERIGROUP|24,851.25|7723.665|8237.19|51.79|||| 806|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W CC|Blue Cross PPO Specialty|BCBSTX PPO|32,715.55|2930.76|8237.19|51.79|||| 806|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W CC|United Healthcare|UNITED HEALTHCARE OTHER|32,263.93|51.79|8237.19|51.79|||| 806|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W CC|Medicaid|MEDICAID|398.60|5180.62|8237.19|51.79|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Medicaid|MEDICAID|260.44|4336.32|27890.3|51.79|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Tricare|TRICARE EAST REGION|30,507.50|2374.03|27890.3|51.79|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Medicaid|MOLINA HEALTHCARE OF TEXAS|253.16|4336.32|27890.3|51.79|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|United Healthcare|UNITED HEALTHCARE|27,117.25|51.79|27890.3|51.79|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|NON CONTRACTED|COMMERCIAL OTHER 1|27,890.30|27890.3|27890.3|51.79|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|United Healthcare|UNITED HEALTHCARE OTHER|22,939.50|51.79|27890.3|51.79|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Blue Cross PPO Specialty|BCBSTX PPO|26,279.50|2543.8|27890.3|51.79|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|23,649.75|2162.51|27890.3|51.79|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|286.57|6047.68|27890.3|51.79|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|27,220.13|6136.92|27890.3|51.79|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|25,770.13|2346.02|27890.3|51.79|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|24,909.13|2292.675|27890.3|51.79|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Managed Medicaid|MEDICAID SUPERIOR|26,121.90|6894.75|27890.3|51.79|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|26,815.13|7565.97|27890.3|51.79|||| 807|DRG||VAGINAL DELIVERY W/O STERILIZATION/D&C W/O CC/MCC|Managed Medicaid|MEDICAID AMERIGROUP|267.55|6894.75|27890.3|51.79|||| 808|DRG||MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL W MCC|Medicare|MEDICARE ACUTE|260.66|17086.32|17086.32|17086.32|||| 81|DRG||NONTRAUMATIC STUPOR & COMA W/O MCC|Medicare|MEDICARE ACUTE|101,280.45|8736.27|8736.27|8736.27|||| 81002|EAP|0300|CLINIC-UA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||26.25||| 81002|EAP|0300|CLINIC-UA|Blue Cross PPO Specialty|BCBSTX PPO|98.25||||26.25||| 81002|EAP|0307|PH URINE|Blue Cross PPO Specialty|BCBSTX PPO|98.25||||||| 81002|EAP|0300|CLINIC-UA|Medicaid|MEDICAID HMO|||||26.25||| 81002|EAP|0300|CLINIC-UA|Managed Medicaid|MEDICAID SUPERIOR|||||26.25||| 81002|EAP|0300|CLINIC-UA|Managed Medicaid|MEDICAID AMERIGROUP|||||26.25||| 81002|EAP|0300|CLINIC-UA|Medicaid|MEDICAID|||||26.25||| 81002|EAP|0300|CLINIC-UA|Medicare|MEDICARE ACUTE|||||26.25||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Managed Medicaid|MEDICAID SUPERIOR|0.86||||0.86||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Managed Medicaid|MEDICAID AMERIGROUP|0.86||||0.86||| 81003|EAP|0307|PROTEIN URINE DIPSTICK|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||22.75||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Medicaid|SUPERIOR HEALTHPLAN CHIP|0.86||||0.20||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Medicaid|MEDICAID TEXAS CHILDRENS|||||0.86||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Managed Medicare|BCBS MEDICARE PPO MA|||||0.53||| 81003|EAP|0307|PROTEIN URINE RANDOM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|98.25||||22.75||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Blue Cross HMO Specialty|BCBSTX HMO|0.86||||0.20||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Aenta Medicare Advantage|AETNA MEDICARE MA|0.86||||0.20||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Access Direct Platinum|HEALTHFIRST TPA UMR|||||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|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||0.20||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.86||||0.20||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Aetna|AETNA PPO|0.86||||0.20||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.86||||0.20||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.86||||0.20||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.86||||0.20||| 81003|EAP|0307|PROTEIN URINE DIPSTICK|Humana Medicare Advantage|HUMANA MA|||||22.75||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Cigna|CIGNA|0.86||||0.20||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Humana Medicare Advantage|HUMANA MA|0.86||||0.20||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Brinson Benefits|THE HEALTH PLAN SMITH CO|0.86||||||| 81003|EAP|0307|PROTEIN URINE RANDOM|Humana Medicare Advantage|HUMANA MA|||||22.75||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Cigna|CIGNA|||||0.20||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Blue Cross PPO Specialty|BCBSTX PPO|0.86||||0.20||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.20||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.86||||0.53||| 81003|EAP|0307|SPECIFIC GRAVITY URINE DI|Blue Cross PPO Specialty|BCBSTX PPO|98.25||||||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|United Healthcare|AARP|||||0.20||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|0.86||||0.20||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|United Healthcare|UNITED HEALTHCARE|0.86||||0.53||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.86||||0.20||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|United Medicare Advantage|UHC MEDICARE GOLD MA|0.86||||0.20||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.86||||0.20||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.86||||0.20||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|0.86||||0.20||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|United Healthcare|UNITED HEALTHCARE|0.86||||0.20||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Veterans Affairs|VETERANS ADMINISTRATION|0.86||||0.86||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|United Healthcare|UNITED HEALTHCARE OTHER|0.86||||0.86||| 81003|EAP|0307|PROTEIN URINE RANDOM|United Medicare Advantage|UHC MEDICARE GOLD MA|||||22.75||| 81003|EAP|0307|PROTEIN URINE RANDOM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||22.75||| 81003|EAP|0307|PROTEIN URINE RANDOM|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||22.75||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.86||||0.20||| 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|Workers Compensation|WORKERS COMPENSATION OTHER|0.86||||0.86||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|United Healthcare|TML GROUP BENEFITS|0.86||||0.20||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.86||||0.86||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.86||||0.86||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Rusk State Hospital|RUSK STATE HOSP|0.86||||0.86||| 81003|EAP|0307|PROTEIN URINE RANDOM|Medicare|MEDICARE ACUTE|||||22.75||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|NON CONTRACTED|COMMERCIAL OTHER 1|0.86||||0.20||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Medicare|MEDICARE ACUTE|0.86||||0.20||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|PHCS|HUMANA INSURANCE|||||0.86||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Medicaid|MEDICAID PCCM|||||0.86||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|NON CONTRACTED|COMMERCIAL OTHER 2|0.86||||0.20||| 81003|EAP|0307|PROTEIN URINE RANDOM|Medicaid|MEDICAID|98.25||||||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Medicaid Out of State|MEDICAID LOUISIANA|||||0.86||| 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|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||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 HMO|||||0.86||| 81003|EAP|0307|PROTEIN URINE RANDOM|Managed Medicare|BCBS MEDICARE PPO MA|||||22.75||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Tricare|TRICARE EAST REGION|0.86||||0.53||| 81003|EAP|0307|PROTEIN URINE RANDOM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||22.75||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Managed Medicare|HOSPICE OF EAST TEXAS|0.86||||0.20||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Managed Medicare|HEALTHSPRING MA|0.86||||0.20||| 81003|EAP|0300|URINALYSIS AUTO/W/0 MICRO|Medicaid|MEDICAID|0.86||||0.86||| 81015|EAP|0300|URINE MICROSCOPIC|NON CONTRACTED|COMMERCIAL OTHER 2|116.50||||27.25||| 81015|EAP|0300|URINE MICROSCOPIC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|116.50||||27.25||| 81015|EAP|0300|URINE MICROSCOPIC|Cigna|CIGNA|||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|Veterans Affairs|VETERANS ADMINISTRATION|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|United Healthcare|UMR UNITED MEDICAL RESOURCES|116.50||||71.88||| 81015|EAP|0300|URINE MICROSCOPIC|Managed Medicare|HEALTHSPRING MA|116.50||||27.25||| 81015|EAP|0300|URINE MICROSCOPIC|Blue Cross PPO Specialty|BCBSTX OTHER|||||27.25||| 81015|EAP|0300|URINE MICROSCOPIC|Medicaid|MOLINA HEALTHCARE OF TEXAS|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|Aenta Medicare Advantage|AETNA MEDICARE MA|116.50||||27.25||| 81015|EAP|0300|URINE MICROSCOPIC|Blue Cross PPO Specialty|BCBSTX PPO|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|Cigna|CIGNA|116.50||||27.25||| 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||||27.25||| 81015|EAP|0300|URINE MICROSCOPIC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||27.25||| 81015|EAP|0300|URINE MICROSCOPIC|Medicaid|MEDICAID|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|116.50||||27.25||| 81015|EAP|0300|URINE MICROSCOPIC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|Managed Medicare|HOSPICE OF EAST TEXAS|116.50||||27.25||| 81015|EAP|0300|URINE MICROSCOPIC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|Aetna|AETNA OTHER|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|Medicaid|MEDICAID PCCM|||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|United Medicare Advantage|UHC MEDICARE GOLD MA|116.50||||27.25||| 81015|EAP|0300|URINE MICROSCOPIC|United Healthcare|UNITED HEALTHCARE|116.50||||71.88||| 81015|EAP|0300|URINE MICROSCOPIC|Medicaid|MEDICAID TEXAS CHILDRENS|||||27.25||| 81015|EAP|0300|URINE MICROSCOPIC|United Healthcare|UNITED HEALTHCARE OTHER|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|116.50||||27.25||| 81015|EAP|0300|URINE MICROSCOPIC|Medicaid Out of State|MEDICAID LOUISIANA|||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||27.25||| 81015|EAP|0300|URINE MICROSCOPIC|United Medicare Advantage|AARP UHC WEST COMPLETE MA|116.50||||27.25||| 81015|EAP|0300|URINE MICROSCOPIC|Medicaid|COUNTY INDIGENT HEALTH OTHER|116.50||||||| 81015|EAP|0300|URINE MICROSCOPIC|Medicaid|MEDICAID HMO|||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|Aetna|AETNA PPO|116.50||||27.25||| 81015|EAP|0300|URINE MICROSCOPIC|Blue Cross HMO Specialty|BCBSTX HMO|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|Tricare|TRICARE EAST REGION|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||27.25||| 81015|EAP|0300|URINE MICROSCOPIC|Rusk State Hospital|RUSK STATE HOSP|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|United Healthcare|TML GROUP BENEFITS|116.50||||27.25||| 81015|EAP|0300|URINE MICROSCOPIC|Workers Compensation|WORKERS COMPENSATION OTHER|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|Medicaid|SUPERIOR HEALTHPLAN CHIP|116.50||||27.25||| 81015|EAP|0300|URINE MICROSCOPIC|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|Managed Medicaid|MEDICAID AMERIGROUP|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|UTMB|UTMB CORRECTIONAL MANAGED CARE|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|NON CONTRACTED|COMMERCIAL OTHER 1|116.50||||27.25||| 81015|EAP|0300|URINE MICROSCOPIC|Managed Medicaid|MEDICAID SUPERIOR|116.50||||116.50||| 81015|EAP|0300|URINE MICROSCOPIC|Medicare|MEDICARE ACUTE|116.50||||27.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Medicare|MEDICARE ACUTE|242.25||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Tricare|TRICARE EAST REGION|242.25||||242.25||| 81025|EAP|0300|CLINIC-PREG TEST,URINE ST|Medicare|MEDICARE ACUTE|242.25||||49.75||| 81025|EAP|0300|PREGNANCY TEST URINE|Managed Medicaid|MEDICAID AMERIGROUP|242.25||||242.25||| 81025|EAP|0300|CLINIC-PREG TEST,URINE ST|Managed Medicaid|MEDICAID AMERIGROUP|242.25||||49.75||| 81025|EAP|0300|PREGNANCY TEST URINE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|NON CONTRACTED|COMMERCIAL OTHER 1|242.25||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Rusk State Hospital|RUSK STATE HOSP|||||242.25||| 81025|EAP|0300|CLINIC-PREG TEST,URINE ST|Medicaid|MEDICAID|242.25||||49.75||| 81025|EAP|0300|PREGNANCY TEST URINE|Aetna|AETNA OTHER|||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Medicaid|MEDICAID PCCM|||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|242.25||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|242.25||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Medicaid|MEDICAID HMO|||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Aenta Medicare Advantage|AETNA MEDICARE MA|242.25||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Blue Cross HMO Specialty|BCBSTX HMO|||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|242.25||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Managed Medicare|HEALTHSPRING 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|Medicaid|MEDICAID|242.25||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Medicaid|MEDICAID TEXAS CHILDRENS|||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Blue Cross PPO Specialty|BCBSTX OTHER|||||242.25||| 81025|EAP|0300|CLINIC-PREG TEST,URINE ST|Blue Cross PPO Specialty|BCBSTX PPO|242.25||||49.75||| 81025|EAP|0300|PREGNANCY TEST URINE|Workers Compensation|WORKERS COMPENSATION OTHER|||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Cigna|CIGNA|||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Aetna|AETNA PPO|242.25||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|242.25||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|United Healthcare|UNITED HEALTHCARE|242.25||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|United Healthcare|UNITED HEALTHCARE OTHER|242.25||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|242.25||||||| 81025|EAP|0300|PREGNANCY TEST URINE|UTMB|UTMB CORRECTIONAL MANAGED CARE|242.25||||||| 81025|EAP|0300|PREGNANCY TEST URINE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Managed Medicaid|MEDICAID SUPERIOR|242.25||||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|United Healthcare|UMR UNITED MEDICAL RESOURCES|242.25||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Humana Medicare Advantage|HUMANA MA|||||242.25||| 81025|EAP|0300|PREGNANCY TEST URINE|Cigna|CIGNA|242.25||||242.25||| 812|DRG||RED BLOOD CELL DISORDERS W/O MCC|Medicare|MEDICARE ACUTE|26,096.65|8857.32|9580.36|8857.32|||| 812|DRG||RED BLOOD CELL DISORDERS W/O MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|305.58|9580.36|9580.36|8857.32|||| 81240|EAP|0301|PROTHROMBIN 20210 ASSAY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||4.19||| 81240|EAP|0301|PROTHROMBIN 20210 ASSAY|Blue Cross PPO Specialty|BCBSTX PPO|||||4.19||| 81240|EAP|0301|PROTHROMBIN 20210 ASSAY|Tricare|TRICARE EAST REGION|||||4.19||| 81240|EAP|0301|PROTHROMBIN 20210 ASSAY|Aenta Medicare Advantage|AETNA MEDICARE MA|||||4.19||| 81241|EAP|0305|FACTOR V LEIDEN|Managed Medicaid|MEDICAID AMERIGROUP|||||520.25||| 81241|EAP|0305|FACTOR V LEIDEN|United Healthcare|UNITED HEALTHCARE|||||520.25||| 81241|EAP|0305|FACTOR V LEIDEN|United Healthcare|UNITED HEALTHCARE OTHER|||||520.25||| 81241|EAP|0305|FACTOR V LEIDEN|Aenta Medicare Advantage|AETNA MEDICARE MA|||||520.25||| 81241|EAP|0305|FACTOR V LEIDEN|Managed Medicaid|MEDICAID SUPERIOR|1,803.25||||||| 81241|EAP|0305|FACTOR V LEIDEN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||520.25||| 81241|EAP|0305|FACTOR V LEIDEN|Blue Cross PPO Specialty|BCBSTX PPO|||||520.25||| 81241|EAP|0305|FACTOR V LEIDEN|Cigna|CIGNA|1,803.25||||||| 81256|EAP|0301|ENZYMATIC DIGESTION|NON CONTRACTED|COMMERCIAL OTHER 1|||||35.75||| 81256|EAP|0301|ENZYMATIC DIGESTION|Blue Cross HMO Specialty|BCBSTX HMO|||||35.75||| 81270|EAP|0300|JAK2 GENE ANALYSIS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||5.85||| 81270|EAP|0300|JAK2 GENE ANALYSIS|Medicare|MEDICARE ACUTE|||||5.85||| 81291|EAP|0300|METHYLENETETRAHYDROFOLATE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||235.75||| 813|DRG||COAGULATION DISORDERS|Medicare|MEDICARE ACUTE|47,496.75|13725.66|13725.66|13725.66|||| 817|DRG||OTHER ANTEPARTUM DIAGNOSES W O.R. PROCEDURE W MCC|Managed Medicaid|MEDICAID SUPERIOR|265.14|16664.23|16664.23|16664.23|||| 818|DRG||OTHER ANTEPARTUM DIAGNOSES W O.R. PROCEDURE W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|41,905.40|9628.06|9628.06|9628.06|||| 82009|EAP|0300|ACETONE,QUALITATIVE|Tricare|TRICARE EAST REGION|||||167.25||| 82009|EAP|0300|ACETONE,QUALITATIVE|Medicare|MEDICARE PART B ONLY IP|167.25||||||| 82009|EAP|0300|ACETONE,QUALITATIVE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||167.25||| 82009|EAP|0300|ACETONE,QUALITATIVE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||167.25||| 82009|EAP|0300|ACETONE,QUALITATIVE|UTMB|UTMB CORRECTIONAL MANAGED CARE|167.25||||167.25||| 82009|EAP|0300|ACETONE,QUALITATIVE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||167.25||| 82009|EAP|0300|ACETONE,QUALITATIVE|United Medicare Advantage|UHC MEDICARE GOLD MA|167.25||||||| 82009|EAP|0300|ACETONE,QUALITATIVE|United Healthcare|UNITED HEALTHCARE|167.25||||||| 82009|EAP|0300|ACETONE,QUALITATIVE|Medicare|MEDICARE ACUTE|167.25||||167.25||| 82009|EAP|0300|ACETONE,QUALITATIVE|United Healthcare|TML GROUP BENEFITS|167.25||||||| 82009|EAP|0300|ACETONE,QUALITATIVE|Managed Medicaid|MEDICAID SUPERIOR|||||167.25||| 82009|EAP|0300|ACETONE,QUALITATIVE|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|167.25||||||| 82009|EAP|0300|ACETONE,QUALITATIVE|Blue Cross PPO Specialty|BCBSTX PPO|167.25||||167.25||| 82009|EAP|0300|ACETONE,QUALITATIVE|United Healthcare|UNITED HEALTHCARE OTHER|||||167.25||| 82024|EAP|0301|ADRENOCORTICOTROPIC HORMO|NON CONTRACTED|COMMERCIAL OTHER 1|||||345.25||| 82024|EAP|0301|ADRENOCORTICOTROPIC HORMO|United Medicare Advantage|UHC MEDICARE GOLD MA|||||345.25||| 82024|EAP|0301|ADRENOCORTICOTROPIC HORMO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||345.25||| 82024|EAP|0301|ADRENOCORTICOTROPIC HORMO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||345.25||| 82024|EAP|0301|ADRENOCORTICOTROPIC HORMO|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||345.25||| 82024|EAP|0301|ADRENOCORTICOTROPIC HORMO|Medicaid|MEDICAID TEXAS CHILDRENS|||||345.25||| 82024|EAP|0301|ADRENOCORTICOTROPIC HORMO|Managed Medicaid|MEDICAID AMERIGROUP|||||345.25||| 82024|EAP|0301|ADRENOCORTICOTROPIC HORMO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||345.25||| 82024|EAP|0301|ADRENOCORTICOTROPIC HORMO|Blue Cross PPO Specialty|BCBSTX PPO|1,328.75||||345.25||| 82024|EAP|0301|ADRENOCORTICOTROPIC HORMO|Blue Cross HMO Specialty|BCBSTX HMO|||||345.25||| 82024|EAP|0301|ADRENOCORTICOTROPIC HORMO|Medicaid|MEDICAID|1,328.75||||||| 82024|EAP|0301|ADRENOCORTICOTROPIC HORMO|Humana Medicare Advantage|HUMANA MA|||||345.25||| 82024|EAP|0301|ADRENOCORTICOTROPIC HORMO|Medicare|MEDICARE ACUTE|||||345.25||| 82040|EAP|0301|ALBUMIN SERUM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|189.75||||||| 82040|EAP|0301|ALBUMIN SERUM|Brinson Benefits|THE HEALTH PLAN SMITH CO|189.75||||||| 82040|EAP|0301|ALBUMIN SERUM|Managed Medicare|HOSPICE OF EAST TEXAS|||||44.25||| 82040|EAP|0301|ALBUMIN SERUM|Medicaid|MEDICAID|||||44.25||| 82040|EAP|0301|ALBUMIN SERUM|Aenta Medicare Advantage|AETNA MEDICARE MA|189.75||||||| 82040|EAP|0301|ALBUMIN SERUM|Medicare|MEDICARE ACUTE|189.75||||||| 82043|EAP|0300|MICROALBUMIN URINE,QUANT|United Medicare Advantage|UHC MEDICARE GOLD MA|||||47.25||| 82043|EAP|0300|MICROALBUMIN URINE,QUANT|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||47.25||| 82043|EAP|0300|MICROALBUMIN URINE,QUANT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||47.25||| 82043|EAP|0300|MICROALBUMIN URINE,QUANT|Aenta Medicare Advantage|AETNA MEDICARE MA|||||47.25||| 82043|EAP|0300|MICROALBUMIN URINE,QUANT|Humana Medicare Advantage|HUMANA MA|||||47.25||| 82043|EAP|0300|MICROALBUMIN URINE,QUANT|Blue Cross HMO Specialty|BCBSTX HMO|||||47.25||| 82043|EAP|0300|MICROALBUMIN URINE,QUANT|United Healthcare|UNITED HEALTHCARE|||||47.25||| 82043|EAP|0300|MICROALBUMIN URINE,QUANT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||47.25||| 82043|EAP|0300|MICROALBUMIN URINE,QUANT|Blue Cross PPO Specialty|BCBSTX PPO|||||47.25||| 82043|EAP|0300|MICROALBUMIN URINE,QUANT|Cigna|CIGNA|||||47.25||| 82043|EAP|0300|MICROALBUMIN URINE,QUANT|Blue Cross PPO Specialty|BCBSTX OTHER|||||47.25||| 82043|EAP|0300|MICROALBUMIN URINE,QUANT|Tricare|TRICARE EAST REGION|||||47.25||| 82043|EAP|0300|MICROALBUMIN URINE,QUANT|Medicare|MEDICARE ACUTE|||||47.25||| 82043|EAP|0300|MICROALBUMIN URINE,QUANT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||47.25||| 82043|EAP|0300|MICROALBUMIN URINE,QUANT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||47.25||| 82043|EAP|0300|MICROALBUMIN URINE,QUANT|Managed Medicaid|MEDICAID SUPERIOR|||||47.25||| 82043|EAP|0300|MICROALBUMIN URINE,QUANT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||47.25||| 82043|EAP|0300|MICROALBUMIN URINE,QUANT|Medicaid|MEDICAID|||||47.25||| 82043|EAP|0300|MICROALBUMIN URINE,QUANT|Managed Medicare|BCBS MEDICARE PPO MA|||||47.25||| 82043|EAP|0300|MICROALBUMIN URINE,QUANT|Managed Medicaid|MEDICAID AMERIGROUP|||||47.25||| 82043|EAP|0300|MICROALBUMIN URINE,QUANT|United Healthcare|UNITED HEALTHCARE OTHER|||||47.25||| 82043|EAP|0300|MICROALBUMIN URINE,QUANT|Aetna|AETNA PPO|||||47.25||| 82043|EAP|0300|MICROALBUMIN URINE,QUANT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||47.25||| 82043|EAP|0300|MICROALBUMIN URINE,QUANT|NON CONTRACTED|COMMERCIAL OTHER 1|||||47.25||| 82044|EAP|0300|MICROALBUMIN, SEMIQUANT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||49.75||| 82044|EAP|0300|MICROALBUMIN, SEMIQUANT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||49.75||| 82044|EAP|0300|MICROALBUMIN, SEMIQUANT|Managed Medicaid|MEDICAID SUPERIOR|||||49.75||| 82044|EAP|0300|MICROALBUMIN, SEMIQUANT|Managed Medicare|HEALTHSPRING MA|||||49.75||| 82044|EAP|0300|MICROALBUMIN, SEMIQUANT|Medicaid|MEDICAID|||||49.75||| 82044|EAP|0300|MICROALBUMIN, SEMIQUANT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||49.75||| 82044|EAP|0300|MICROALBUMIN, SEMIQUANT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||49.75||| 82044|EAP|0300|MICROALBUMIN, SEMIQUANT|Managed Medicaid|MEDICAID AMERIGROUP|||||49.75||| 82044|EAP|0300|MICROALBUMIN, SEMIQUANT|Blue Cross PPO Specialty|BCBSTX PPO|||||49.75||| 82044|EAP|0300|MICROALBUMIN, SEMIQUANT|Cigna|CIGNA|||||49.75||| 82044|EAP|0300|MICROALBUMIN, SEMIQUANT|Medicare|MEDICARE ACUTE|||||49.75||| 82044|EAP|0300|MICROALBUMIN, SEMIQUANT|Humana Medicare Advantage|HUMANA MA|||||49.75||| 82044|EAP|0300|MICROALBUMIN, SEMIQUANT|Blue Cross HMO Specialty|BCBSTX HMO|||||49.75||| 82044|EAP|0300|MICROALBUMIN, SEMIQUANT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||49.75||| 82044|EAP|0300|MICROALBUMIN, SEMIQUANT|Aenta Medicare Advantage|AETNA MEDICARE MA|||||49.75||| 82044|EAP|0300|MICROALBUMIN, SEMIQUANT|United Healthcare|UNITED HEALTHCARE OTHER|||||49.75||| 82044|EAP|0300|MICROALBUMIN, SEMIQUANT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||49.75||| 82044|EAP|0300|MICROALBUMIN, SEMIQUANT|NON CONTRACTED|COMMERCIAL OTHER 1|||||49.75||| 82044|EAP|0300|MICROALBUMIN, SEMIQUANT|Aetna|AETNA PPO|||||49.75||| 82044|EAP|0300|MICROALBUMIN, SEMIQUANT|United Medicare Advantage|UHC MEDICARE GOLD MA|49.75||||49.75||| 82044|EAP|0300|MICROALBUMIN, SEMIQUANT|United Healthcare|UNITED HEALTHCARE|||||49.75||| 82044|EAP|0300|MICROALBUMIN, SEMIQUANT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||49.75||| 82044|EAP|0300|MICROALBUMIN, SEMIQUANT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||49.75||| 82044|EAP|0300|MICROALBUMIN, SEMIQUANT|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||49.75||| 82085|EAP|0300|ALDOLASE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||86.75||| 82085|EAP|0300|ALDOLASE|Blue Cross HMO Specialty|BCBSTX HMO|||||86.75||| 82085|EAP|0300|ALDOLASE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||86.75||| 82085|EAP|0300|ALDOLASE|United Medicare Advantage|UHC MEDICARE GOLD MA|371.75||||||| 82085|EAP|0300|ALDOLASE|Medicare|MEDICARE ACUTE|||||86.75||| 82085|EAP|0300|ALDOLASE|Blue Cross PPO Specialty|BCBSTX PPO|||||86.75||| 82085|EAP|0300|ALDOLASE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||86.75||| 82085|EAP|0300|ALDOLASE|Humana Medicare Advantage|HUMANA MA|||||86.75||| 82085|EAP|0300|ALDOLASE|Managed Medicaid|MEDICAID AMERIGROUP|||||86.75||| 82085|EAP|0300|ALDOLASE|Medicaid|MEDICAID|||||86.75||| 82085|EAP|0300|ALDOLASE|Managed Medicaid|MEDICAID SUPERIOR|||||86.75||| 82085|EAP|0300|ALDOLASE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||86.75||| 82088|EAP|0301|ALDOSTERONE SERUM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||364.25||| 82088|EAP|0301|ALDOSTERONE 24 HR URINE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||364.25||| 82088|EAP|0301|ALDOSTERONE SERUM|Humana Medicare Advantage|HUMANA MA|13.37||||364.25||| 82088|EAP|0301|ALDOSTERONE SERUM|Blue Cross PPO Specialty|BCBSTX PPO|13.37||||364.25||| 82088|EAP|0301|ALDOSTERONE SERUM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||850.63||| 82088|EAP|0301|ALDOSTERONE SERUM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||364.25||| 82088|EAP|0301|ALDOSTERONE SERUM|United Medicare Advantage|UHC MEDICARE GOLD MA|||||364.25||| 82088|EAP|0301|ALDOSTERONE SERUM|Blue Cross HMO Specialty|BCBSTX HMO|||||364.25||| 82088|EAP|0301|ALDOSTERONE SERUM|Medicare|MEDICARE ACUTE|||||364.25||| 82088|EAP|0301|ALDOSTERONE SERUM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||364.25||| 82088|EAP|0301|ALDOSTERONE SERUM|NON CONTRACTED|COMMERCIAL OTHER 1|||||364.25||| 82088|EAP|0301|ALDOSTERONE SERUM|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||364.25||| 82103|EAP|0301|ALPHA I ANTITRYPSIN|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.20||| 82103|EAP|0301|ALPHA I ANTITRYPSIN|Managed Medicaid|MEDICAID AMERIGROUP|514.50||||||| 82103|EAP|0301|ALPHA I ANTITRYPSIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.20||| 82105|EAP|0301|ALPHA FETO PROTEIN TUMOR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1.50||| 82105|EAP|0301|ALPHA FETO PROTEIN PREGNA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|642.50||||1.50||| 82105|EAP|0301|ALPHA FETO PROTEIN PREGNA|Managed Medicaid|MEDICAID AMERIGROUP|||||1.50||| 82105|EAP|0301|ALPHA FETO PROTEIN PREGNA|Managed Medicaid|MEDICAID SUPERIOR|||||1.50||| 82105|EAP|0301|ALPHA FETO PROTEIN PREGNA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1.50||| 82105|EAP|0301|ALPHA FETO PROTEIN PREGNA|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.50||| 82105|EAP|0301|ALPHA FETO PROTEIN TUMOR|Managed Medicaid|MEDICAID SUPERIOR|||||1.50||| 82105|EAP|0301|ALPHA FETO PROTEIN TUMOR|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1.50||| 82105|EAP|0301|ALPHA FETO PROTEIN TUMOR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|642.50||||1.50||| 82105|EAP|0301|ALPHA FETO PROTEIN TUMOR|Medicaid|MEDICAID|||||1.50||| 82105|EAP|0301|ALPHA FETO PROTEIN PREGNA|United Healthcare|UNITED HEALTHCARE OTHER|||||1.50||| 82105|EAP|0301|ALPHA FETO PROTEIN TUMOR|Humana Medicare Advantage|HUMANA MA|||||1.50||| 82105|EAP|0301|ALPHA FETO PROTEIN TUMOR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.50||| 82105|EAP|0301|ALPHA FETO PROTEIN PREGNA|Blue Cross PPO Specialty|BCBSTX PPO|||||1.50||| 82105|EAP|0301|ALPHA FETO PROTEIN TUMOR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|642.50||||||| 82105|EAP|0301|ALPHA FETO PROTEIN PREGNA|Blue Cross HMO Specialty|BCBSTX HMO|||||1.50||| 82105|EAP|0301|ALPHA FETO PROTEIN TUMOR|NON CONTRACTED|COMMERCIAL OTHER 1|||||1.50||| 82105|EAP|0301|ALPHA FETO PROTEIN TUMOR|Managed Medicare|HEALTHSPRING MA|||||1.50||| 82105|EAP|0301|ALPHA FETO PROTEIN PREGNA|Medicaid|MEDICAID|||||1.50||| 82105|EAP|0301|ALPHA FETO PROTEIN PREGNA|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||1.50||| 82105|EAP|0301|ALPHA FETO PROTEIN PREGNA|Tricare|TRICARE EAST REGION|||||1.50||| 82105|EAP|0301|ALPHA FETO PROTEIN TUMOR|Medicare|MEDICARE ACUTE|642.50||||1.50||| 82139|EAP|0300|AMINO ACID,QUANT,PLASMA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.89||| 82140|EAP|0300|AMMONIA BLOOD|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||558.50||| 82140|EAP|0300|AMMONIA BLOOD|Medicaid|MEDICAID|558.50||||||| 82140|EAP|0300|AMMONIA BLOOD|Managed Medicaid|MEDICAID SUPERIOR|||||130.25||| 82140|EAP|0300|AMMONIA BLOOD|UTMB|UTMB CORRECTIONAL MANAGED CARE|558.50||||558.50||| 82140|EAP|0300|AMMONIA BLOOD|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|558.50||||130.25||| 82140|EAP|0300|AMMONIA BLOOD|Rusk State Hospital|RUSK STATE HOSP|558.50||||558.50||| 82140|EAP|0300|AMMONIA BLOOD|Blue Cross PPO Specialty|BCBSTX PPO|558.50||||130.25||| 82140|EAP|0300|AMMONIA BLOOD|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||130.25||| 82140|EAP|0300|AMMONIA BLOOD|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||130.25||| 82140|EAP|0300|AMMONIA BLOOD|Managed Medicare|HEALTHSPRING MA|558.50||||||| 82140|EAP|0300|AMMONIA BLOOD|NON CONTRACTED|COMMERCIAL OTHER 1|||||130.25||| 82140|EAP|0300|AMMONIA BLOOD|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|558.50||||130.25||| 82140|EAP|0300|AMMONIA BLOOD|Managed Medicaid|MEDICAID UNITED HEALTHCARE|558.50||||130.25||| 82140|EAP|0300|AMMONIA BLOOD|Blue Cross HMO Specialty|BCBSTX HMO|558.50||||558.50||| 82140|EAP|0300|AMMONIA BLOOD|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|558.50||||||| 82140|EAP|0300|AMMONIA BLOOD|Humana Medicare Advantage|HUMANA MA|558.50||||130.25||| 82140|EAP|0300|AMMONIA BLOOD|United Medicare Advantage|UHC MEDICARE GOLD MA|558.50||||130.25||| 82140|EAP|0300|AMMONIA BLOOD|Medicare|MEDICARE ACUTE|558.50||||130.25||| 82150|EAP|0300|AMYLASE SERUM|Humana Medicare Advantage|HUMANA MA|2.48||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Blue Cross PPO Specialty|BCBSTX OTHER|2.48||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Blue Cross HMO Specialty|BCBSTX HMO|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|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.48||||2.48||| 82150|EAP|0300|AMYLASE SERUM|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||1.53||| 82150|EAP|0300|AMYLASE SERUM|United Medicare Advantage|UHC MEDICARE GOLD 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|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.48||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Access Direct Platinum|HEALTHFIRST TPA UMR|||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Aenta Medicare Advantage|AETNA MEDICARE MA|2.48||||1.53||| 82150|EAP|0300|AMYLASE SERUM|United Healthcare|UNITED HEALTHCARE OTHER|||||0.58||| 82150|EAP|0300|AMYLASE SERUM|Blue Cross PPO Specialty|BCBSTX PPO|2.48||||2.48||| 82150|EAP|0300|AMYLASE SERUM|United Medicare Advantage|AARP UHC WEST COMPLETE MA|2.48||||0.58||| 82150|EAP|0300|AMYLASE SERUM|Cigna|CIGNA|2.48||||1.53||| 82150|EAP|0300|AMYLASE SERUM|Workers Compensation|WORKERS COMPENSATION OTHER|||||2.48||| 82150|EAP|0300|AMYLASE SERUM|United Healthcare|TML GROUP BENEFITS|||||0.58||| 82150|EAP|0300|AMYLASE SERUM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.48||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Veterans Affairs|VETERANS ADMINISTRATION|2.48||||2.48||| 82150|EAP|0300|AMYLASE SERUM|United Healthcare|UNITED HEALTHCARE|2.48||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Medicare|MEDICARE ACUTE|2.48||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Medicaid|MOLINA HEALTHCARE OF TEXAS|2.48||||2.48||| 82150|EAP|0300|AMYLASE SERUM|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.48||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Tricare|TRICARE EAST REGION|||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Medicaid|MEDICAID HMO|||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Managed Medicare|HOSPICE OF EAST TEXAS|2.48||||||| 82150|EAP|0300|AMYLASE SERUM|Medicaid|MEDICAID PCCM|||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Medicaid|SUPERIOR HEALTHPLAN CHIP|2.48||||1.53||| 82150|EAP|0300|AMYLASE SERUM|NON CONTRACTED|COMMERCIAL OTHER 1|2.48||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Cigna|CIGNA|||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||2.48||| 82150|EAP|0300|AMYLASE SERUM|United Healthcare|UMR UNITED MEDICAL RESOURCES|2.48||||0.58||| 82150|EAP|0300|AMYLASE SERUM|Medicaid|MEDICAID|2.48||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Medicaid|MEDICAID TEXAS CHILDRENS|||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.48||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Rusk State Hospital|RUSK STATE HOSP|2.48||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.48||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.48||||0.58||| 82150|EAP|0300|AMYLASE SERUM|Managed Medicaid|MEDICAID SUPERIOR|2.48||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Managed Medicare|HEALTHSPRING MA|||||0.58||| 82150|EAP|0300|AMYLASE SERUM|Managed Medicaid|MEDICAID AMERIGROUP|2.48||||2.48||| 82150|EAP|0300|AMYLASE SERUM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.48||||2.48||| 82164|EAP|0301|ANGIOTENSIN CONVERTING EN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|559.25||||||| 82164|EAP|0301|ANGIOTENSIN CONVERTING EN|Blue Cross PPO Specialty|BCBSTX PPO|||||130.50||| 82164|EAP|0301|ANGIOTENSIN CONVERTING EN|Humana Medicare Advantage|HUMANA MA|||||130.50||| 82164|EAP|0301|ANGIOTENSIN CONVERTING EN|Medicare|MEDICARE ACUTE|559.25||||||| 82164|EAP|0301|ANGIOTENSIN CONVERTING EN|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||130.50||| 82175|EAP|0301|ARSENIC|Humana Medicare Advantage|HUMANA MA|||||169.50||| 82180|EAP|0301|VITAMIN C|Humana Medicare Advantage|HUMANA MA|||||88.25||| 82180|EAP|0301|VITAMIN C|Managed Medicaid|MEDICAID AMERIGROUP|||||88.25||| 82232|EAP|0301|BETA 2 MICROGLOBIN SERUM|Blue Cross PPO Specialty|BCBSTX PPO|||||144.50||| 82232|EAP|0301|BETA 2 MICROGLOBIN SERUM|Medicare|MEDICARE ACUTE|||||144.50||| 82247|EAP|0300|BILIRUBIN TOTAL|Medicaid|MEDICAID|192.25||||44.75||| 82247|EAP|0300|BILIRUBIN TOTAL|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||44.75||| 82247|EAP|0300|BILIRUBIN TOTAL|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||44.75||| 82247|EAP|0300|BILIRUBIN TOTAL|Managed Medicaid|MEDICAID SUPERIOR|192.25||||44.75||| 82247|EAP|0300|BILIRUBIN TOTAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|192.25||||||| 82247|EAP|0300|BILIRUBIN TOTAL|Blue Cross PPO Specialty|BCBSTX OTHER|||||192.25||| 82247|EAP|0300|BILIRUBIN TOTAL|Tricare|TRICARE EAST REGION|192.25||||44.75||| 82247|EAP|0300|BILIRUBIN TOTAL|Managed Medicaid|MEDICAID AMERIGROUP|192.25||||44.75||| 82247|EAP|0300|BILIRUBIN TOTAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|192.25||||44.75||| 82247|EAP|0300|BILIRUBIN TOTAL|NON CONTRACTED|COMMERCIAL OTHER 1|192.25||||44.75||| 82247|EAP|0300|BILIRUBIN TOTAL|Blue Cross PPO Specialty|BCBSTX PPO|192.25||||44.75||| 82247|EAP|0300|BILIRUBIN TOTAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|192.25||||44.75||| 82247|EAP|0300|BILIRUBIN TOTAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|192.25||||||| 82247|EAP|0300|BILIRUBIN TOTAL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|192.25||||||| 82247|EAP|0300|BILIRUBIN TOTAL|Blue Cross HMO Specialty|BCBSTX HMO|192.25||||44.75||| 82247|EAP|0300|BILIRUBIN TOTAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||44.75||| 82248|EAP|0300|BILIRUBIN DIRECT|Tricare|TRICARE EAST REGION|192.25||||44.75||| 82248|EAP|0300|BILIRUBIN DIRECT|Blue Cross PPO Specialty|BCBSTX OTHER|||||192.25||| 82248|EAP|0300|BILIRUBIN DIRECT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|192.25||||44.75||| 82248|EAP|0300|BILIRUBIN DIRECT|Medicaid|MEDICAID|192.25||||44.75||| 82248|EAP|0300|BILIRUBIN DIRECT|Aetna|AETNA PPO|||||44.75||| 82248|EAP|0300|BILIRUBIN DIRECT|Blue Cross PPO Specialty|BCBSTX PPO|192.25||||44.75||| 82248|EAP|0300|BILIRUBIN DIRECT|Blue Cross HMO Specialty|BCBSTX HMO|192.25||||44.75||| 82248|EAP|0300|BILIRUBIN DIRECT|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||44.75||| 82248|EAP|0300|BILIRUBIN DIRECT|United Medicare Advantage|UHC MEDICARE GOLD MA|192.25||||||| 82248|EAP|0300|BILIRUBIN DIRECT|NON CONTRACTED|COMMERCIAL OTHER 1|192.25||||44.75||| 82248|EAP|0300|BILIRUBIN DIRECT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||44.75||| 82248|EAP|0300|BILIRUBIN DIRECT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|192.25||||44.75||| 82248|EAP|0300|BILIRUBIN DIRECT|Managed Medicaid|MEDICAID AMERIGROUP|192.25||||44.75||| 82248|EAP|0300|BILIRUBIN DIRECT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||44.75||| 82248|EAP|0300|BILIRUBIN DIRECT|Managed Medicaid|MEDICAID SUPERIOR|192.25||||44.75||| 82248|EAP|0300|BILIRUBIN DIRECT|Medicaid|MEDICAID TEXAS CHILDRENS|||||44.75||| 82248|EAP|0300|BILIRUBIN DIRECT|Medicare|MEDICARE ACUTE|||||44.75||| 82248|EAP|0300|BILIRUBIN DIRECT|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||44.75||| 82248|EAP|0300|BILIRUBIN DIRECT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|192.25||||||| 82261|EAP|0300|BIOTINIDASE|Managed Medicaid|MEDICAID SUPERIOR|||||0.89||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|Managed Medicaid|MEDICAID AMERIGROUP|||||0.29||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||124.50||| 82270|EAP|0300|CLINIC-OCCULT BLOOD-3 TES|United Medicare Advantage|AARP UHC WEST COMPLETE MA|124.50||||26.25||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|United Healthcare|UNITED HEALTHCARE|||||0.29||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|United Healthcare|TML GROUP BENEFITS|||||0.29||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|United Medicare Advantage|AARP UHC WEST COMPLETE MA|124.50||||0.29||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|124.50||||0.29||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|Aetna|AETNA OTHER|||||124.50||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|United Medicare Advantage|UHC MEDICARE GOLD MA|124.50||||0.29||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|Workers Compensation|UT EMPLOYEE INJURY|124.50||||||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|Veterans Affairs|VETERANS ADMINISTRATION|124.50||||124.50||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|Blue Cross HMO Specialty|BCBSTX HMO|124.50||||124.50||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|124.50||||0.29||| 82270|EAP|0300|CLINIC-OCCULT BLOOD-3 TES|United Medicare Advantage|UHC MEDICARE GOLD MA|124.50||||26.25||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|Workers Compensation|WORKERS COMPENSATION OTHER|124.50||||124.50||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|124.50||||76.75||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|United Healthcare|UNITED HEALTHCARE OTHER|||||0.29||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|Cigna|CIGNA|124.50||||||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.29||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|Aetna|AETNA PPO|124.50||||||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|Blue Cross PPO Specialty|BCBSTX PPO|||||0.29||| 82270|EAP|0300|CLINIC-OCCULT BLOOD-3 TES|Humana Medicare Advantage|HUMANA MA|124.50||||26.25||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|Aenta Medicare Advantage|AETNA MEDICARE MA|124.50||||76.75||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||0.29||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|Medicare|MEDICARE ACUTE|124.50||||0.29||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|Humana Medicare Advantage|HUMANA MA|124.50||||0.29||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|124.50||||0.29||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|Tricare|TRICARE EAST REGION|||||0.29||| 82270|EAP|0300|CLINIC-OCCULT BLOOD-3 TES|Medicare|MEDICARE ACUTE|124.50||||26.25||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|Medicaid|MOLINA HEALTHCARE OF TEXAS|124.50||||||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|124.50||||124.50||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|Medicaid|MEDICAID|124.50||||0.29||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|NON CONTRACTED|COMMERCIAL OTHER 1|124.50||||0.29||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|Blue Cross PPO Specialty|BCBSTX OTHER|||||76.75||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|Medicaid|MEDICAID HMO|||||0.29||| 82270|EAP|0300|CLINIC-OCCULT BLOOD-3 TES|Managed Medicaid|MEDICAID AMERIGROUP|||||26.25||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|Managed Medicaid|MEDICAID UNITED HEALTHCARE|124.50||||0.29||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|Managed Medicaid|MEDICAID SUPERIOR|124.50||||0.29||| 82270|EAP|0300|OCCULT BLOOD FECES QT.|Medicaid|SUPERIOR HEALTHPLAN CHIP|124.50||||0.29||| 82271|EAP|0300|OCCULT BLOOD, GASTRIC|Blue Cross HMO Specialty|BCBSTX HMO|||||124.50||| 82271|EAP|0300|OCCULT BLOOD, GASTRIC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|124.50||||||| 82271|EAP|0300|OCCULT BLOOD, GASTRIC|Medicare|MEDICARE ACUTE|124.50||||124.50||| 82271|EAP|0300|OCCULT BLOOD, GASTRIC|Humana Medicare Advantage|HUMANA MA|||||124.50||| 82300|EAP|0301|CADMIUM (SERUM)|Blue Cross PPO Specialty|BCBSTX PPO|||||886.50||| 82306|EAP|0300|VITAMIN D,25 OH|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||242.75||| 82306|EAP|0300|VITAMIN D,25 OH|NON CONTRACTED|COMMERCIAL OTHER 1|||||242.75||| 82306|EAP|0300|VITAMIN D,25 OH|Tricare|TRICARE EAST REGION|||||242.75||| 82306|EAP|0300|VITAMIN D,25 OH|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||242.75||| 82306|EAP|0300|VITAMIN D,25 OH|Managed Medicaid|MEDICAID AMERIGROUP|1,040.75||||242.75||| 82306|EAP|0300|VITAMIN D,25 OH|Medicaid|MEDICAID|1,040.75||||242.75||| 82306|EAP|0300|VITAMIN D,25 OH|Managed Medicare|HEALTHSPRING MA|||||242.75||| 82306|EAP|0300|VITAMIN D,25 OH|Managed Medicaid|MEDICAID SUPERIOR|||||242.75||| 82306|EAP|0300|VITAMIN D,25 OH|Medicare|MEDICARE ACUTE|242.75||||242.75||| 82306|EAP|0300|VITAMIN D,25 OH|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||242.75||| 82306|EAP|0300|VITAMIN D,25 OH|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||242.75||| 82306|EAP|0300|VITAMIN D,25 OH|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||242.75||| 82306|EAP|0300|VITAMIN D,25 OH|United Healthcare|UNITED HEALTHCARE|||||242.75||| 82306|EAP|0300|VITAMIN D,25 OH|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||242.75||| 82306|EAP|0300|VITAMIN D,25 OH|Veterans Affairs|VETERANS ADMINISTRATION|||||242.75||| 82306|EAP|0300|VITAMIN D,25 OH|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||242.75||| 82306|EAP|0300|VITAMIN D,25 OH|Medicaid|MEDICAID TEXAS CHILDRENS|||||242.75||| 82306|EAP|0300|VITAMIN D,25 OH|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||242.75||| 82306|EAP|0300|VITAMIN D,25 OH|Aetna|AETNA OTHER|||||242.75||| 82306|EAP|0300|VITAMIN D,25 OH|United Healthcare|UNITED HEALTHCARE OTHER|||||242.75||| 82306|EAP|0300|VITAMIN D,25 OH|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||242.75||| 82306|EAP|0300|VITAMIN D,25 OH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,040.75||||242.75||| 82306|EAP|0300|VITAMIN D,25 OH|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||242.75||| 82306|EAP|0300|VITAMIN D,25 OH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||242.75||| 82306|EAP|0300|VITAMIN D,25 OH|Blue Cross PPO Specialty|BCBSTX OTHER|||||242.75||| 82306|EAP|0300|VITAMIN D,25 OH|Humana Medicare Advantage|HUMANA MA|1,040.75||||242.75||| 82306|EAP|0300|VITAMIN D,25 OH|United Healthcare|TML GROUP BENEFITS|||||242.75||| 82306|EAP|0300|VITAMIN D,25 OH|Aenta Medicare Advantage|AETNA MEDICARE MA|||||242.75||| 82306|EAP|0300|VITAMIN D,25 OH|Blue Cross PPO Specialty|BCBSTX PPO|||||242.75||| 82306|EAP|0300|VITAMIN D,25 OH|Blue Cross HMO Specialty|BCBSTX HMO|||||242.75||| 82306|EAP|0300|VITAMIN D,25 OH|Cigna|CIGNA|||||242.75||| 82306|EAP|0300|VITAMIN D,25 OH|Aetna|AETNA PPO|||||242.75||| 82306|EAP|0300|VITAMIN D,25 OH|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||242.75||| 82306|EAP|0300|VITAMIN D,25 OH|Rusk State Hospital|RUSK STATE HOSP|||||242.75||| 82306|EAP|0300|VITAMIN D,25 OH|United Medicare Advantage|UHC MEDICARE GOLD MA|||||242.75||| 82308|EAP|0301|CALCITONIN|Medicare|MEDICARE ACUTE|||||239.25||| 82308|EAP|0301|CALCITONIN|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||239.25||| 82310|EAP|0300|CALCIUM SERUM|Humana Medicare Advantage|HUMANA MA|||||0.46||| 82310|EAP|0300|CALCIUM SERUM|Medicare|MEDICARE ACUTE|197.50||||||| 82310|EAP|0300|CALCIUM SERUM|Medicaid|MEDICAID|||||0.46||| 82330|EAP|0301|CALCIUM, IONIZED|Medicare|MEDICARE ACUTE|523.50||||1.22||| 82330|EAP|0301|CALCIUM, IONIZED|Managed Medicaid|MEDICAID AMERIGROUP|||||1.22||| 82330|EAP|0301|CALCIUM, IONIZED|Humana Medicare Advantage|HUMANA MA|||||1.22||| 82330|EAP|0301|CALCIUM, IONIZED|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1.22||| 82330|EAP|0301|CALCIUM, IONIZED|UTMB|UTMB CORRECTIONAL MANAGED CARE|523.50||||||| 82340|EAP|0301|CALCIUM 24HR URINE|Humana Medicare Advantage|HUMANA MA|||||0.54||| 82340|EAP|0301|CALCIUM RANDOM URINE|Medicare|MEDICARE ACUTE|197.50||||||| 82340|EAP|0301|CALCIUM 24HR URINE|Blue Cross PPO Specialty|BCBSTX PPO|||||0.54||| 82370|EAP|0300|CALCIUM,TOTAL X-RAY DIFFR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1.07||| 82374|EAP|0301|C02|Medicaid|MEDICAID|||||43.75||| 82375|EAP|0301|CARBON MONOXIDE CARBOXYHE|Humana Medicare Advantage|HUMANA MA|||||110.25||| 82378|EAP|0300|CEA CARCINOEMBRYONIC ANTI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||169.50||| 82378|EAP|0300|CEA CARCINOEMBRYONIC ANTI|Managed Medicare|HEALTHSPRING MA|||||169.50||| 82378|EAP|0300|CEA CARCINOEMBRYONIC ANTI|Medicare|MEDICARE ACUTE|726.50||||169.50||| 82378|EAP|0300|CEA CARCINOEMBRYONIC ANTI|United Medicare Advantage|UHC MEDICARE GOLD MA|||||169.50||| 82378|EAP|0300|CEA CARCINOEMBRYONIC ANTI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||726.50||| 82378|EAP|0300|CEA CARCINOEMBRYONIC ANTI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||169.50||| 82378|EAP|0300|CEA CARCINOEMBRYONIC ANTI|Blue Cross PPO Specialty|BCBSTX PPO|||||726.50||| 82378|EAP|0300|CEA CARCINOEMBRYONIC ANTI|Humana Medicare Advantage|HUMANA MA|726.50||||169.50||| 82378|EAP|0300|CEA CARCINOEMBRYONIC ANTI|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||169.50||| 82378|EAP|0300|CEA CARCINOEMBRYONIC ANTI|Aenta Medicare Advantage|AETNA MEDICARE MA|||||169.50||| 82378|EAP|0300|CEA CARCINOEMBRYONIC ANTI|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|726.50||||||| 82379|EAP|0300|CARNITINE|Managed Medicaid|MEDICAID SUPERIOR|||||0.89||| 82379|EAP|0300|CARNITINE|Blue Cross HMO Specialty|BCBSTX HMO|||||0.89||| 82380|EAP|0300|CAROTENE|Managed Medicaid|MEDICAID SUPERIOR|||||82.50||| 82384|EAP|0301|CATECHOLAMINES|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||225.75||| 82384|EAP|0301|CATECHOLAMINES|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||225.75||| 82384|EAP|0301|CATECHOLAMINES|United Medicare Advantage|UHC MEDICARE GOLD MA|||||225.75||| 82384|EAP|0301|CATECHOLAMINES|Medicare|MEDICARE ACUTE|967.75||||225.75||| 82384|EAP|0301|CATECHOLAMINES|NON CONTRACTED|COMMERCIAL OTHER 1|||||225.75||| 82384|EAP|0301|CATECHOLAMINES|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||225.75||| 82384|EAP|0301|CATECHOLAMINES|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||225.75||| 82384|EAP|0301|CATECHOLAMINES|Managed Medicaid|MEDICAID SUPERIOR|967.75||||225.75||| 82384|EAP|0301|CATECHOLAMINES|Humana Medicare Advantage|HUMANA MA|||||225.75||| 82390|EAP|0301|CERULOPLASMIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.96||| 82390|EAP|0301|CERULOPLASMIN|Medicare|MEDICARE ACUTE|411.50||||||| 82397|EAP|0300|PTH RELATED HORMONE|Blue Cross PPO Specialty|BCBSTX PPO|||||2.24||| 82397|EAP|0300|INSULIN-LIKE GROWTH FACTO|Medicare|MEDICARE ACUTE|||||1.90||| 82397|EAP|0300|INSULIN-LIKE GROWTH FACTO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1.90||| 82435|EAP|0300|CHLORIDE|Medicaid|MEDICAID|||||0.41||| 82436|EAP|0300|CHLORIDE RANDOM URINE|Humana Medicare Advantage|HUMANA MA|192.50||||||| 82436|EAP|0300|CHLORIDE RANDOM URINE|Medicaid|MEDICAID|192.50||||||| 82465|EAP|0300|CHOLESTEROL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.39||| 82465|EAP|0300|CHOLESTEROL|Medicare|MEDICARE ACUTE|||||0.39||| 82465|EAP|0300|CHOLESTEROL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.39||| 82465|EAP|0300|CHOLESTEROL|Blue Cross HMO Specialty|BCBSTX HMO|||||0.39||| 82465|EAP|0300|CHOLESTEROL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|167.25||||||| 82523|EAP|0300|C-TELOPEPTIDE, SERUM|Medicare|MEDICARE ACUTE|||||203.44||| 82525|EAP|0300|COPPER SERUM|Medicare|MEDICARE ACUTE|||||1.11||| 82525|EAP|0300|COPPER 24HR URINE|United Healthcare|UNITED HEALTHCARE OTHER|||||1.11||| 82530|EAP|0301|CORTISOL,FREE 24HR URINE|Medicare|MEDICARE ACUTE|||||149.50||| 82530|EAP|0301|CORTISOL,FREE 24HR URINE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||149.50||| 82530|EAP|0301|CORTISOL,FREE 24HR URINE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||149.50||| 82530|EAP|0301|CORTISOL,FREE 24HR URINE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||149.50||| 82530|EAP|0300|CORTISOL FREE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||149.50||| 82533|EAP|0300|CORTISOL|Managed Medicaid|MEDICAID SUPERIOR|624.75||||145.75||| 82533|EAP|0300|CORTISOL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||145.75||| 82533|EAP|0300|CORTISOL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||145.75||| 82533|EAP|0300|CORTISOL|United Medicare Advantage|UHC MEDICARE GOLD MA|624.75||||145.75||| 82533|EAP|0300|CORTISOL|Humana Medicare Advantage|HUMANA MA|||||145.75||| 82533|EAP|0300|CORTISOL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||145.75||| 82533|EAP|0300|CORTISOL|Blue Cross PPO Specialty|BCBSTX PPO|624.75||||145.75||| 82533|EAP|0300|CORTISOL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||145.75||| 82533|EAP|0300|CORTISOL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||145.75||| 82533|EAP|0300|CORTISOL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|624.75||||||| 82533|EAP|0300|CORTISOL|Aenta Medicare Advantage|AETNA MEDICARE MA|624.75||||||| 82533|EAP|0300|CORTISOL|Medicare|MEDICARE ACUTE|624.75||||145.75||| 82533|EAP|0300|CORTISOL|Blue Cross HMO Specialty|BCBSTX HMO|||||145.75||| 82533|EAP|0300|CORTISOL|UTMB|UTMB CORRECTIONAL MANAGED CARE|624.75||||||| 82533|EAP|0300|CORTISOL|Veterans Affairs|VETERANS ADMINISTRATION|624.75||||||| 82533|EAP|0300|CORTISOL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||145.75||| 82533|EAP|0300|CORTISOL|NON CONTRACTED|COMMERCIAL OTHER 1|||||145.75||| 82533|EAP|0300|CORTISOL|Medicaid|MEDICAID|624.75||||||| 82550|EAP|0301|CK (CREATINE KINASE)|Aetna|AETNA OTHER|||||58.25||| 82550|EAP|0301|CK (CREATINE KINASE)|Managed Medicaid|MEDICAID UNITED HEALTHCARE|249.75||||249.75||| 82550|EAP|0301|CK (CREATINE KINASE)|Managed Medicaid|MEDICAID SUPERIOR|249.75||||1.54||| 82550|EAP|0301|CK (CREATINE KINASE)|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|249.75||||249.75||| 82550|EAP|0301|CK (CREATINE KINASE)|Medicaid|COUNTY INDIGENT HEALTH OTHER|249.75||||249.75||| 82550|EAP|0301|CK (CREATINE KINASE)|Medicaid|MEDICAID|249.75||||249.75||| 82550|EAP|0301|CK (CREATINE KINASE)|Rusk State Hospital|RUSK STATE HOSP|249.75||||249.75||| 82550|EAP|0301|CK (CREATINE KINASE)|UTMB|UTMB CORRECTIONAL MANAGED CARE|249.75||||249.75||| 82550|EAP|0301|CK (CREATINE KINASE)|Medicare|MEDICARE ACUTE|249.75||||249.75||| 82550|EAP|0301|CK (CREATINE KINASE)|NON CONTRACTED|COMMERCIAL OTHER 1|249.75||||249.75||| 82550|EAP|0301|CK (CREATINE KINASE)|Tricare|TRICARE EAST REGION|||||249.75||| 82550|EAP|0301|CK (CREATINE KINASE)|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||58.25||| 82550|EAP|0301|CK (CREATINE KINASE)|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|249.75||||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 HMO Specialty|BCBSTX HMO|249.75||||249.75||| 82550|EAP|0301|CK (CREATINE KINASE)|Managed Medicaid|MEDICAID AMERIGROUP|||||1.54||| 82550|EAP|0301|CK (CREATINE KINASE)|Blue Cross PPO Specialty|BCBSTX PPO|249.75||||249.75||| 82550|EAP|0301|CK (CREATINE KINASE)|United Healthcare|UNITED HEALTHCARE|||||249.75||| 82550|EAP|0301|CK (CREATINE KINASE)|Medicare|MEDICARE PART B ONLY IP|249.75||||||| 82550|EAP|0301|CK (CREATINE KINASE)|United Medicare Advantage|UHC MEDICARE GOLD MA|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)|United Healthcare|UNITED HEALTHCARE|249.75||||249.75||| 82550|EAP|0301|CK (CREATINE KINASE)|Managed Medicare|HEALTHSPRING MA|||||249.75||| 82550|EAP|0301|CK (CREATINE KINASE)|Aetna|AETNA PPO|||||1.54||| 82550|EAP|0301|CK (CREATINE KINASE)|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|249.75||||1.54||| 82550|EAP|0301|CK (CREATINE KINASE)|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|249.75||||249.75||| 82550|EAP|0301|CK (CREATINE KINASE)|United Healthcare|GEHA|||||249.75||| 82550|EAP|0301|CK (CREATINE KINASE)|Blue Cross PPO Specialty|BCBSTX OTHER|249.75||||249.75||| 82550|EAP|0301|CK (CREATINE KINASE)|Workers Compensation|WORKERS COMPENSATION OTHER|||||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||||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)|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||249.75||| 82550|EAP|0301|CK (CREATINE KINASE)|Workers Compensation|UT EMPLOYEE INJURY|249.75||||||| 82550|EAP|0301|CK (CREATINE KINASE)|United Healthcare|UNITED HEALTHCARE OTHER|||||58.25||| 82550|EAP|0301|CK (CREATINE KINASE)|Veterans Affairs|VETERANS ADMINISTRATION|249.75||||249.75||| 82550|EAP|0301|CK (CREATINE KINASE)|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||249.75||| 82550|EAP|0301|CK (CREATINE KINASE)|Cigna|CIGNA|||||249.75||| 82552|EAP|0301|CK ISOENZYMES|Managed Medicaid|MEDICAID UNITED HEALTHCARE|513.25||||||| 82552|EAP|0301|CK ISOENZYMES|Medicaid|MEDICAID|||||119.75||| 82552|EAP|0301|CK ISOENZYMES|Blue Cross PPO Specialty|BCBSTX PPO|||||316.50||| 82553|EAP|0301|CKMB|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|235.75||||235.75||| 82553|EAP|0301|CKMB|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|235.75||||235.75||| 82553|EAP|0301|CKMB|Managed Medicaid|MEDICAID UNITED HEALTHCARE|235.75||||235.75||| 82553|EAP|0301|CKMB|Medicaid|SUPERIOR HEALTHPLAN CHIP|235.75||||||| 82553|EAP|0301|CKMB|Managed Medicare|HEALTHSPRING MA|||||235.75||| 82553|EAP|0301|CKMB|NON CONTRACTED|COMMERCIAL OTHER 1|235.75||||235.75||| 82553|EAP|0301|CKMB|Rusk State Hospital|RUSK STATE HOSP|235.75||||235.75||| 82553|EAP|0301|CKMB|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||235.75||| 82553|EAP|0301|CKMB|UTMB|UTMB CORRECTIONAL MANAGED CARE|235.75||||235.75||| 82553|EAP|0301|CKMB|Managed Medicaid|MEDICAID SUPERIOR|235.75||||235.75||| 82553|EAP|0301|CKMB|Medicare|MEDICARE PART B ONLY IP|235.75||||||| 82553|EAP|0301|CKMB|United Healthcare|UNITED HEALTHCARE|235.75||||235.75||| 82553|EAP|0301|CKMB|Managed Medicaid|MEDICAID AMERIGROUP|||||235.75||| 82553|EAP|0301|CKMB|United Healthcare|UNITED HEALTHCARE OTHER|||||235.75||| 82553|EAP|0301|CKMB|Medicaid|MEDICAID|235.75||||235.75||| 82553|EAP|0301|CKMB|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||235.75||| 82553|EAP|0301|CKMB|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|235.75||||235.75||| 82553|EAP|0301|CKMB|Veterans Affairs|VETERANS ADMINISTRATION|235.75||||235.75||| 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|Workers Compensation|WORKERS COMPENSATION OTHER|||||235.75||| 82553|EAP|0301|CKMB|United Medicare Advantage|AARP UHC WEST COMPLETE MA|235.75||||235.75||| 82553|EAP|0301|CKMB|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||235.75||| 82553|EAP|0301|CKMB|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||235.75||| 82553|EAP|0301|CKMB|Aenta Medicare Advantage|AETNA MEDICARE MA|235.75||||235.75||| 82553|EAP|0301|CKMB|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|235.75||||235.75||| 82553|EAP|0301|CKMB|Medicare|MEDICARE ACUTE|235.75||||235.75||| 82553|EAP|0301|CKMB|Cigna|CIGNA|||||235.75||| 82553|EAP|0301|CKMB|Blue Cross PPO Specialty|BCBSTX OTHER|235.75||||235.75||| 82553|EAP|0301|CKMB|Blue Cross HMO Specialty|BCBSTX HMO|235.75||||235.75||| 82553|EAP|0301|CKMB|Aetna|AETNA PPO|||||235.75||| 82553|EAP|0301|CKMB|Humana Medicare Advantage|HUMANA MA|235.75||||235.75||| 82553|EAP|0301|CKMB|Blue Cross PPO Specialty|BCBSTX PPO|235.75||||235.75||| 82553|EAP|0301|CKMB|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|235.75||||235.75||| 82565|EAP|0300|CREATININE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1.21||| 82565|EAP|0300|CREATININE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||45.75||| 82565|EAP|0300|CREATININE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||45.75||| 82565|EAP|0300|CREATININE|Cigna|CIGNA|||||45.75||| 82565|EAP|0300|CREATININE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|196.25||||45.75||| 82565|EAP|0300|CREATININE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||45.75||| 82565|EAP|0300|CREATININE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|196.25||||45.75||| 82565|EAP|0300|CREATININE|Blue Cross HMO Specialty|BCBSTX HMO|196.25||||45.75||| 82565|EAP|0300|CREATININE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|196.25||||45.75||| 82565|EAP|0300|CREATININE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||45.75||| 82565|EAP|0300|CREATININE|Blue Cross PPO Specialty|BCBSTX OTHER|||||45.75||| 82565|EAP|0300|CREATININE|United Healthcare|UNITED HEALTHCARE OTHER|||||45.75||| 82565|EAP|0300|CREATININE|Humana Medicare Advantage|HUMANA MA|196.25||||45.75||| 82565|EAP|0300|CREATININE|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||45.75||| 82565|EAP|0300|CREATININE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|196.25||||45.75||| 82565|EAP|0300|CREATININE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||45.75||| 82565|EAP|0300|CREATININE|Managed Medicare|BCBS MEDICARE PPO MA|||||45.75||| 82565|EAP|0300|CREATININE|Medicaid|MEDICAID|196.25||||45.75||| 82565|EAP|0300|CREATININE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||45.75||| 82565|EAP|0300|CREATININE|Blue Cross PPO Specialty|BCBSTX PPO|196.25||||45.75||| 82565|EAP|0300|CREATININE|Managed Medicaid|MEDICAID SUPERIOR|196.25||||45.75||| 82565|EAP|0300|CREATININE|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||45.75||| 82565|EAP|0300|CREATININE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|196.25||||45.75||| 82565|EAP|0300|CREATININE|Managed Medicare|HEALTHSPRING MA|196.25||||45.75||| 82565|EAP|0300|CREATININE|NON CONTRACTED|COMMERCIAL OTHER 1|196.25||||45.75||| 82565|EAP|0300|CREATININE|United Healthcare|TML GROUP BENEFITS|||||45.75||| 82565|EAP|0300|CREATININE|Veterans Affairs|VETERANS ADMINISTRATION|||||45.75||| 82565|EAP|0300|CREATININE|Tricare|TRICARE EAST REGION|||||45.75||| 82565|EAP|0300|CREATININE|Medicare|MEDICARE ACUTE|196.25||||45.75||| 82570|EAP|0300|CREATININE URINE, RANDOM|Tricare|TRICARE EAST REGION|||||46.25||| 82570|EAP|0300|CREATININE URINE, RANDOM|Managed Medicaid|MEDICAID SUPERIOR|||||46.25||| 82570|EAP|0300|CREATININE URINE, RANDOM|NON CONTRACTED|COMMERCIAL OTHER 1|||||46.25||| 82570|EAP|0300|CREATININE URINE, RANDOM|Medicaid|MEDICAID|||||46.25||| 82570|EAP|0300|CREATININE URINE, RANDOM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||46.25||| 82570|EAP|0300|CREATININE URINE, RANDOM|Managed Medicaid|MEDICAID AMERIGROUP|||||46.25||| 82570|EAP|0300|CREATININE URINE, RANDOM|Medicare|MEDICARE ACUTE|||||46.25||| 82570|EAP|0300|24 HOUR URINE CREATININE|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||46.25||| 82570|EAP|0300|CREATININE URINE, RANDOM|Managed Medicare|BCBS MEDICARE PPO MA|||||46.25||| 82570|EAP|0300|24 HOUR URINE CREATININE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||46.25||| 82570|EAP|0300|CREATININE URINE, RANDOM|United Healthcare|UNITED HEALTHCARE|||||46.25||| 82570|EAP|0300|CREATININE URINE, RANDOM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||46.25||| 82570|EAP|0300|CREATININE URINE, RANDOM|United Healthcare|UNITED HEALTHCARE OTHER|||||46.25||| 82570|EAP|0300|CREATININE URINE, RANDOM|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||46.25||| 82570|EAP|0300|CREATININE URINE, RANDOM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||46.25||| 82570|EAP|0300|CREATININE URINE, RANDOM|Blue Cross HMO Specialty|BCBSTX HMO|||||46.25||| 82570|EAP|0300|CREATININE URINE, RANDOM|Aenta Medicare Advantage|AETNA MEDICARE MA|||||46.25||| 82570|EAP|0300|24 HOUR URINE CREATININE|Blue Cross HMO Specialty|BCBSTX HMO|||||46.25||| 82570|EAP|0300|24 HOUR URINE CREATININE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||46.25||| 82570|EAP|0300|CREATININE URINE, RANDOM|Aetna|AETNA PPO|||||46.25||| 82570|EAP|0300|24 HOUR URINE CREATININE|Blue Cross PPO Specialty|BCBSTX OTHER|||||46.25||| 82570|EAP|0300|24 HOUR URINE CREATININE|Medicare|MEDICARE ACUTE|||||46.25||| 82570|EAP|0300|24 HOUR URINE CREATININE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||46.25||| 82570|EAP|0300|CREATININE URINE, RANDOM|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||46.25||| 82570|EAP|0300|24 HOUR URINE CREATININE|Blue Cross PPO Specialty|BCBSTX PPO|||||46.25||| 82570|EAP|0300|CREATININE URINE, RANDOM|Humana Medicare Advantage|HUMANA MA|||||46.25||| 82570|EAP|0300|CREATININE URINE, RANDOM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||46.25||| 82570|EAP|0300|CREATININE URINE, RANDOM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||46.25||| 82570|EAP|0300|CREATININE URINE, RANDOM|United Medicare Advantage|UHC MEDICARE GOLD MA|||||46.25||| 82570|EAP|0300|CREATININE URINE, RANDOM|Blue Cross PPO Specialty|BCBSTX OTHER|||||46.25||| 82570|EAP|0300|24 HOUR URINE CREATININE|Humana Medicare Advantage|HUMANA MA|||||46.25||| 82570|EAP|0300|CREATININE URINE, RANDOM|Cigna|CIGNA|||||46.25||| 82570|EAP|0300|CREATININE URINE, RANDOM|Blue Cross PPO Specialty|BCBSTX PPO|||||46.25||| 82575|EAP|0300|CREATININE CLEARANCE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||84.50||| 82575|EAP|0300|CREATININE CLEARANCE|Blue Cross PPO Specialty|BCBSTX OTHER|||||84.50||| 82575|EAP|0300|CREATININE CLEARANCE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|361.50||||||| 82575|EAP|0300|CREATININE CLEARANCE|Blue Cross HMO Specialty|BCBSTX HMO|||||84.50||| 82575|EAP|0300|CREATININE CLEARANCE|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||84.50||| 82575|EAP|0300|CREATININE CLEARANCE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||84.50||| 82575|EAP|0300|CREATININE CLEARANCE|Managed Medicaid|MEDICAID SUPERIOR|361.50||||||| 82575|EAP|0300|CREATININE CLEARANCE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||84.50||| 82575|EAP|0300|CREATININE CLEARANCE|Blue Cross PPO Specialty|BCBSTX PPO|||||84.50||| 82575|EAP|0300|CREATININE CLEARANCE|Humana Medicare Advantage|HUMANA MA|||||84.50||| 82575|EAP|0300|CREATININE CLEARANCE|Medicare|MEDICARE ACUTE|||||84.50||| 82585|EAP|0301|CRYOFEBRINOGEN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||76.75||| 82595|EAP|0301|CRYOGLOBULIN QUALITATIVE|Humana Medicare Advantage|HUMANA MA|||||57.75||| 82595|EAP|0301|CRYOGLOBULIN QUANTITATIVE|Humana Medicare Advantage|HUMANA MA|||||57.75||| 82607|EAP|0301|VITAMIN B-12|Tricare|TRICARE EAST REGION|||||134.75||| 82607|EAP|0301|VITAMIN B-12|NON CONTRACTED|COMMERCIAL OTHER 1|577.50||||134.75||| 82607|EAP|0301|VITAMIN B-12|Medicare|MEDICARE ACUTE|577.50||||134.75||| 82607|EAP|0301|VITAMIN B-12|UTMB|UTMB CORRECTIONAL MANAGED CARE|577.50||||||| 82607|EAP|0301|VITAMIN B-12|Medicaid|MEDICAID HMO|||||134.75||| 82607|EAP|0301|VITAMIN B-12|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|577.50||||134.75||| 82607|EAP|0301|VITAMIN B-12|Managed Medicare|HEALTHSPRING MA|577.50||||134.75||| 82607|EAP|0301|VITAMIN B-12|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||134.75||| 82607|EAP|0301|VITAMIN B-12|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||134.75||| 82607|EAP|0301|VITAMIN B-12|Medicaid|MEDICAID TEXAS CHILDRENS|||||134.75||| 82607|EAP|0301|VITAMIN B-12|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||134.75||| 82607|EAP|0301|VITAMIN B-12|Medicaid|MEDICAID|577.50||||134.75||| 82607|EAP|0301|VITAMIN B-12|United Healthcare|UNITED HEALTHCARE OTHER|||||134.75||| 82607|EAP|0301|VITAMIN B-12|Managed Medicaid|MEDICAID SUPERIOR|||||134.75||| 82607|EAP|0301|VITAMIN B-12|Managed Medicaid|MEDICAID AMERIGROUP|||||134.75||| 82607|EAP|0301|VITAMIN B-12|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||134.75||| 82607|EAP|0301|VITAMIN B-12|Rusk State Hospital|RUSK STATE HOSP|||||134.75||| 82607|EAP|0301|VITAMIN B-12|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||134.75||| 82607|EAP|0301|VITAMIN B-12|United Medicare Advantage|UHC MEDICARE GOLD MA|577.50||||134.75||| 82607|EAP|0301|VITAMIN B-12|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||134.75||| 82607|EAP|0301|VITAMIN B-12|United Healthcare|UNITED HEALTHCARE|||||134.75||| 82607|EAP|0301|VITAMIN B-12|Blue Cross PPO Specialty|BCBSTX OTHER|||||134.75||| 82607|EAP|0301|VITAMIN B-12|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||134.75||| 82607|EAP|0301|VITAMIN B-12|Brinson Benefits|THE HEALTH PLAN SMITH CO|577.50||||||| 82607|EAP|0301|VITAMIN B-12|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||134.75||| 82607|EAP|0301|VITAMIN B-12|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||134.75||| 82607|EAP|0301|VITAMIN B-12|Aenta Medicare Advantage|AETNA MEDICARE MA|||||134.75||| 82607|EAP|0301|VITAMIN B-12|Humana Medicare Advantage|HUMANA MA|577.50||||134.75||| 82607|EAP|0301|VITAMIN B-12|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||134.75||| 82607|EAP|0301|VITAMIN B-12|Veterans Affairs|VETERANS ADMINISTRATION|||||134.75||| 82607|EAP|0301|VITAMIN B-12|Aetna|AETNA PPO|||||134.75||| 82607|EAP|0301|VITAMIN B-12|Blue Cross HMO Specialty|BCBSTX HMO|577.50||||134.75||| 82607|EAP|0301|VITAMIN B-12|Blue Cross PPO Specialty|BCBSTX PPO|577.50||||134.75||| 82607|EAP|0301|VITAMIN B-12|Cigna|CIGNA|||||134.75||| 82607|EAP|0301|VITAMIN B-12|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||134.75||| 82607|EAP|0301|VITAMIN B-12|Workers Compensation|WORKERS COMPENSATION OTHER|577.50||||134.75||| 82608|EAP|0301|VITAMIN B-12 UNSATURATED|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.28||| 82608|EAP|0301|VITAMIN B-12 UNSATURATED|Medicare|MEDICARE ACUTE|||||1.28||| 82610|EAP|0300|CYSTATIN C|Medicaid|MEDICAID TEXAS CHILDRENS|||||0.93||| 82626|EAP|0301|DHEA UNCONJUGATED|Humana Medicare Advantage|HUMANA MA|||||2.26||| 82626|EAP|0301|DHEA UNCONJUGATED|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||2.26||| 82626|EAP|0301|DHEA UNCONJUGATED|United Medicare Advantage|UHC MEDICARE GOLD MA|||||2.26||| 82626|EAP|0301|DHEA UNCONJUGATED|Blue Cross PPO Specialty|BCBSTX PPO|||||2.26||| 82626|EAP|0301|DHEA UNCONJUGATED|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.26||| 82626|EAP|0301|DHEA UNCONJUGATED|Blue Cross HMO Specialty|BCBSTX HMO|||||2.26||| 82626|EAP|0301|DHEA UNCONJUGATED|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.26||| 82626|EAP|0301|DHEA UNCONJUGATED|Medicare|MEDICARE ACUTE|||||2.26||| 82626|EAP|0301|DHEA UNCONJUGATED|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||2.26||| 82626|EAP|0301|DHEA UNCONJUGATED|Managed Medicaid|MEDICAID SUPERIOR|||||2.26||| 82626|EAP|0301|DHEA UNCONJUGATED|NON CONTRACTED|COMMERCIAL OTHER 1|||||2.26||| 82627|EAP|0301|DHEA-SULFATE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||851.75||| 82627|EAP|0301|DHEA-SULFATE|Blue Cross PPO Specialty|BCBSTX PPO|851.75||||851.75||| 82627|EAP|0301|DHEA-SULFATE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||851.75||| 82627|EAP|0301|DHEA-SULFATE|Managed Medicaid|MEDICAID AMERIGROUP|||||851.75||| 82627|EAP|0301|DHEA-SULFATE|Managed Medicaid|MEDICAID SUPERIOR|||||851.75||| 82652|EAP|0300|VITAMIN D 1,25 DIHYDROXY|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||304.50||| 82652|EAP|0300|VITAMIN D 1,25 DIHYDROXY|Cigna|CIGNA|||||304.50||| 82652|EAP|0300|VITAMIN D 1,25 DIHYDROXY|Humana Medicare Advantage|HUMANA MA|1,328.50||||304.50||| 82652|EAP|0300|VITAMIN D 1,25 DIHYDROXVI|Medicare|MEDICARE ACUTE|1,328.50||||3.44||| 82652|EAP|0300|VITAMIN D 1,25 DIHYDROXY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,328.50||||||| 82652|EAP|0300|VITAMIN D 1,25 DIHYDROXY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||304.50||| 82652|EAP|0300|VITAMIN D 1,25 DIHYDROXY|Managed Medicaid|MEDICAID SUPERIOR|||||1,328.50||| 82652|EAP|0300|VITAMIN D 1,25 DIHYDROXY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||304.50||| 82652|EAP|0300|VITAMIN D 1,25 DIHYDROXY|Medicare|MEDICARE ACUTE|1,328.50||||304.50||| 82652|EAP|0300|VITAMIN D 1,25 DIHYDROXY|Medicaid|MEDICAID|1,328.50||||||| 82668|EAP|0300|ERYTHROPOIETIN|Medicare|MEDICARE ACUTE|||||1.68||| 82668|EAP|0300|ERYTHROPOIETIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.68||| 82670|EAP|0301|ESTRADIOL|United Healthcare|UNITED HEALTHCARE|||||249.75||| 82670|EAP|0301|ESTRADIOL|United Healthcare|TML GROUP BENEFITS|||||249.75||| 82670|EAP|0301|ESTRADIOL|Blue Cross PPO Specialty|BCBSTX OTHER|||||249.75||| 82670|EAP|0301|ESTRADIOL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||249.75||| 82670|EAP|0301|ESTRADIOL|Humana Medicare Advantage|HUMANA MA|||||249.75||| 82670|EAP|0301|ESTRADIOL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||249.75||| 82670|EAP|0301|ESTRADIOL|Blue Cross PPO Specialty|BCBSTX PPO|||||249.75||| 82670|EAP|0301|ESTRADIOL|Cigna|CIGNA|||||249.75||| 82670|EAP|0301|ESTRADIOL|Access Direct Platinum|HEALTHFIRST TPA UMR|||||249.75||| 82670|EAP|0301|ESTRADIOL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||249.75||| 82670|EAP|0301|ESTRADIOL|Medicare|MEDICARE ACUTE|||||249.75||| 82670|EAP|0301|ESTRADIOL|Managed Medicaid|MEDICAID SUPERIOR|||||249.75||| 82670|EAP|0301|ESTRADIOL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||249.75||| 82670|EAP|0301|ESTRADIOL|Tricare|TRICARE EAST REGION|||||249.75||| 82670|EAP|0301|ESTRADIOL|NON CONTRACTED|COMMERCIAL OTHER 1|||||249.75||| 82670|EAP|0301|ESTRADIOL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||249.75||| 82670|EAP|0301|ESTRADIOL|Blue Cross HMO Specialty|BCBSTX HMO|||||249.75||| 82671|EAP|0300|ESTROGEN|Blue Cross PPO Specialty|BCBSTX PPO|||||285.50||| 82677|EAP|0300|ESTRIOL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||216.25||| 82677|EAP|0300|ESTRIOL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||216.25||| 82677|EAP|0300|ESTRIOL|Blue Cross PPO Specialty|BCBSTX PPO|||||216.25||| 82677|EAP|0300|ESTRIOL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||216.25||| 82677|EAP|0300|ESTRIOL|Medicare|MEDICARE ACUTE|||||216.25||| 82677|EAP|0300|ESTRIOL|Blue Cross HMO Specialty|BCBSTX HMO|||||216.25||| 82705|EAP|0301|FECAL FAT, QUALITATIVE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||45.50||| 82705|EAP|0301|FECAL FAT, QUALITATIVE|Blue Cross HMO Specialty|BCBSTX HMO|||||45.50||| 82705|EAP|0301|FECAL FAT, QUALITATIVE|Managed Medicaid|MEDICAID AMERIGROUP|||||45.50||| 82705|EAP|0301|FECAL FAT, QUALITATIVE|Medicare|MEDICARE ACUTE|||||45.50||| 82728|EAP|0301|FERRITIN|Medicare|MEDICARE ACUTE|521.50||||121.75||| 82728|EAP|0301|FERRITIN|Medicaid|MEDICAID TEXAS CHILDRENS|||||121.75||| 82728|EAP|0301|FERRITIN|PHCS|HUMANA INSURANCE|||||121.75||| 82728|EAP|0301|FERRITIN|Managed Medicaid|MEDICAID SUPERIOR|||||121.75||| 82728|EAP|0301|FERRITIN|NON CONTRACTED|COMMERCIAL OTHER 1|521.50||||121.75||| 82728|EAP|0301|FERRITIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|521.50||||121.75||| 82728|EAP|0301|FERRITIN|Medicaid|MEDICAID HMO|||||121.75||| 82728|EAP|0301|FERRITIN|Medicaid|COUNTY INDIGENT HEALTH OTHER|521.50||||||| 82728|EAP|0301|FERRITIN|Managed Medicaid|MEDICAID AMERIGROUP|||||121.75||| 82728|EAP|0301|FERRITIN|Managed Medicare|HEALTHSPRING MA|521.50||||121.75||| 82728|EAP|0301|FERRITIN|Tricare|TRICARE EAST REGION|||||121.75||| 82728|EAP|0301|FERRITIN|Medicaid|MEDICAID|521.50||||121.75||| 82728|EAP|0301|FERRITIN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||121.75||| 82728|EAP|0301|FERRITIN|United Healthcare|UNITED HEALTHCARE OTHER|||||121.75||| 82728|EAP|0301|FERRITIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|521.50||||121.75||| 82728|EAP|0301|FERRITIN|Workers Compensation|WORKERS COMPENSATION OTHER|521.50||||121.75||| 82728|EAP|0301|FERRITIN|United Healthcare|UNITED HEALTHCARE|||||121.75||| 82728|EAP|0301|FERRITIN|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||121.75||| 82728|EAP|0301|FERRITIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||121.75||| 82728|EAP|0301|FERRITIN|United Medicare Advantage|AARP UHC WEST COMPLETE MA|521.50||||121.75||| 82728|EAP|0301|FERRITIN|United Medicare Advantage|UHC MEDICARE GOLD MA|521.50||||121.75||| 82728|EAP|0301|FERRITIN|Rusk State Hospital|RUSK STATE HOSP|521.50||||521.50||| 82728|EAP|0301|FERRITIN|Medicaid|SUPERIOR HEALTHPLAN CHIP|521.50||||321.63||| 82728|EAP|0301|FERRITIN|United Healthcare|UNITED HEALTHCARE|521.50||||321.63||| 82728|EAP|0301|FERRITIN|Blue Cross PPO Specialty|BCBSTX OTHER|||||121.75||| 82728|EAP|0301|FERRITIN|Brinson Benefits|THE HEALTH PLAN SMITH CO|521.50||||||| 82728|EAP|0301|FERRITIN|Humana Medicare Advantage|HUMANA MA|521.50||||121.75||| 82728|EAP|0301|FERRITIN|Cigna|CIGNA|||||521.50||| 82728|EAP|0301|FERRITIN|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||121.75||| 82728|EAP|0301|FERRITIN|Blue Cross PPO Specialty|BCBSTX PPO|521.50||||121.75||| 82728|EAP|0301|FERRITIN|Cigna|CIGNA|||||121.75||| 82728|EAP|0301|FERRITIN|Workers Compensation|UT EMPLOYEE INJURY|521.50||||||| 82728|EAP|0301|FERRITIN|UTMB|UTMB CORRECTIONAL MANAGED CARE|521.50||||521.50||| 82728|EAP|0301|FERRITIN|Aetna|AETNA OTHER|||||121.75||| 82728|EAP|0301|FERRITIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|521.50||||121.75||| 82728|EAP|0301|FERRITIN|Access Direct Platinum|HEALTHFIRST TPA UMR|||||121.75||| 82728|EAP|0301|FERRITIN|Aenta Medicare Advantage|AETNA MEDICARE MA|||||121.75||| 82728|EAP|0301|FERRITIN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||121.75||| 82728|EAP|0301|FERRITIN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||121.75||| 82728|EAP|0301|FERRITIN|Blue Cross HMO Specialty|BCBSTX HMO|521.50||||121.75||| 82728|EAP|0301|FERRITIN|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||121.75||| 82728|EAP|0301|FERRITIN|Aetna|AETNA PPO|||||321.63||| 82746|EAP|0300|FOLIC ACID|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||131.50||| 82746|EAP|0300|FOLIC ACID|Blue Cross HMO Specialty|BCBSTX HMO|||||131.50||| 82746|EAP|0300|FOLIC ACID|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||131.50||| 82746|EAP|0300|FOLIC ACID|Aenta Medicare Advantage|AETNA MEDICARE MA|||||131.50||| 82746|EAP|0300|FOLIC ACID|Blue Cross PPO Specialty|BCBSTX PPO|||||131.50||| 82746|EAP|0300|FOLIC ACID|Blue Cross PPO Specialty|BCBSTX OTHER|||||131.50||| 82746|EAP|0300|FOLIC ACID|Cigna|CIGNA|||||131.50||| 82746|EAP|0300|FOLIC ACID|Humana Medicare Advantage|HUMANA MA|||||131.50||| 82746|EAP|0300|FOLIC ACID|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||131.50||| 82746|EAP|0300|FOLIC ACID|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||131.50||| 82746|EAP|0300|FOLIC ACID|United Healthcare|UNITED HEALTHCARE|||||131.50||| 82746|EAP|0300|FOLIC ACID|United Healthcare|UNITED HEALTHCARE OTHER|||||131.50||| 82746|EAP|0300|FOLIC ACID|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||131.50||| 82746|EAP|0300|FOLIC ACID|Veterans Affairs|VETERANS ADMINISTRATION|||||131.50||| 82746|EAP|0300|FOLIC ACID|Managed Medicaid|MEDICAID SUPERIOR|||||131.50||| 82746|EAP|0300|FOLIC ACID|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||131.50||| 82746|EAP|0300|FOLIC ACID|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||131.50||| 82746|EAP|0300|FOLIC ACID|Managed Medicaid|MEDICAID AMERIGROUP|||||131.50||| 82746|EAP|0300|FOLIC ACID|Medicaid|MEDICAID TEXAS CHILDRENS|||||131.50||| 82746|EAP|0300|FOLIC ACID|Workers Compensation|WORKERS COMPENSATION OTHER|||||131.50||| 82746|EAP|0300|FOLIC ACID|Medicaid|MEDICAID|563.25||||131.50||| 82746|EAP|0300|FOLIC ACID|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||131.50||| 82746|EAP|0300|FOLIC ACID|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||131.50||| 82746|EAP|0300|FOLIC ACID|Managed Medicare|HEALTHSPRING MA|||||131.50||| 82746|EAP|0300|FOLIC ACID|NON CONTRACTED|COMMERCIAL OTHER 1|563.25||||131.50||| 82746|EAP|0300|FOLIC ACID|United Medicare Advantage|UHC MEDICARE GOLD MA|||||131.50||| 82746|EAP|0300|FOLIC ACID|Rusk State Hospital|RUSK STATE HOSP|||||131.50||| 82746|EAP|0300|FOLIC ACID|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||131.50||| 82746|EAP|0300|FOLIC ACID|Tricare|TRICARE EAST REGION|||||131.50||| 82746|EAP|0300|FOLIC ACID|Medicare|MEDICARE ACUTE|563.25||||131.50||| 82746|EAP|0300|FOLIC ACID|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||131.50||| 82747|EAP|0300|FOLATE (FOLIC ACID) RBC|Medicare|MEDICARE ACUTE|662.25||||154.50||| 82747|EAP|0300|FOLATE (FOLIC ACID) RBC|Medicaid|MEDICAID|662.25||||||| 82747|EAP|0300|FOLATE (FOLIC ACID) RBC|Managed Medicare|HEALTHSPRING MA|662.25||||||| 82747|EAP|0300|FOLATE (FOLIC ACID) RBC|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||154.50||| 82747|EAP|0300|FOLATE (FOLIC ACID) RBC|Workers Compensation|WORKERS COMPENSATION OTHER|662.25||||||| 82747|EAP|0300|FOLATE (FOLIC ACID) RBC|Blue Cross HMO Specialty|BCBSTX HMO|||||408.38||| 82747|EAP|0300|FOLATE (FOLIC ACID) RBC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|662.25||||||| 82747|EAP|0300|FOLATE (FOLIC ACID) RBC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||154.50||| 82747|EAP|0300|FOLATE (FOLIC ACID) RBC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||154.50||| 82784|EAP|0300|IMMUNOGLOBULIN A|Blue Cross HMO Specialty|BCBSTX HMO|||||0.83||| 82784|EAP|0300|IMMUNOGLOBULIN G|Blue Cross HMO Specialty|BCBSTX HMO|||||0.83||| 82784|EAP|0300|IMMUNOGLOBULIN G|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||0.83||| 82784|EAP|0300|IMMUNOGLOBULIN A|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.83||| 82784|EAP|0301|IMMUNOGLOBULINS IGG/IGA/I|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||0.83||| 82784|EAP|0300|IMMUNOGLOBULIN A|Managed Medicaid|MEDICAID SUPERIOR|||||0.83||| 82784|EAP|0300|IMMUNOGLOBULIN G|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.83||| 82784|EAP|0301|IMMUNOGLOBULIN M|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.83||| 82784|EAP|0301|IMMUNOGLOBULINS IGG/IGA/I|Managed Medicaid|MEDICAID SUPERIOR|||||0.83||| 82784|EAP|0301|IMMUNOGLOBULINS IGG/IGA/I|Medicare|MEDICARE ACUTE|356.50||||0.83||| 82784|EAP|0300|IMMUNOGLOBULIN A|Medicare|MEDICARE ACUTE|356.50||||0.83||| 82784|EAP|0300|IMMUNOGLOBULIN G|Humana Medicare Advantage|HUMANA MA|||||0.83||| 82784|EAP|0300|IMMUNOGLOBULIN G|Medicare|MEDICARE ACUTE|356.50||||0.83||| 82785|EAP|0301|IMMUNOGLOBULIN E|Blue Cross PPO Specialty|BCBSTX PPO|||||147.25||| 82785|EAP|0301|IMMUNOGLOBULIN E|Medicare|MEDICARE ACUTE|||||147.25||| 82785|EAP|0301|IMMUNOGLOBULIN E|Managed Medicaid|MEDICAID SUPERIOR|||||147.25||| 82785|EAP|0301|IMMUNOGLOBULIN E|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||147.25||| 82785|EAP|0301|IMMUNOGLOBULIN E|Blue Cross HMO Specialty|BCBSTX HMO|||||147.25||| 82785|EAP|0301|IMMUNOGLOBULIN E|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||147.25||| 82785|EAP|0301|IMMUNOGLOBULIN E|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||147.25||| 82785|EAP|0301|IMMUNOGLOBULIN E|Humana Medicare Advantage|HUMANA MA|||||147.25||| 82785|EAP|0301|IMMUNOGLOBULIN E|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||147.25||| 82787|EAP|0300|IGG SUBCLASS III|Medicare|MEDICARE ACUTE|||||37.50||| 82787|EAP|0300|IGG SUBCLASS IV|Medicare|MEDICARE ACUTE|||||37.50||| 82787|EAP|0300|IGG SUBCLASS I|Medicare|MEDICARE ACUTE|||||37.50||| 82787|EAP|0300|IGG SUBCLASS II|Medicare|MEDICARE ACUTE|||||37.50||| 82803|EAP|0300|ARTERIAL BLOOD GASES|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||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|AARP UHC WEST COMPLETE MA|741.25||||741.25||| 82803|EAP|0300|ARTERIAL BLOOD GASES|Humana Medicare Advantage|HUMANA MA|741.25||||741.25||| 82803|EAP|0300|ARTERIAL BLOOD GASES|Cigna|CIGNA|741.25||||741.25||| 82803|EAP|0300|ARTERIAL BLOOD GASES|Blue Cross PPO Specialty|BCBSTX PPO|741.25||||741.25||| 82803|EAP|0300|CAPILLARY BLOOD GAS|Blue Cross PPO Specialty|BCBSTX PPO|370.75||||741.25||| 82803|EAP|0300|ARTERIAL BLOOD GASES|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|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|Blue Cross PPO Specialty|BCBSTX OTHER|741.25||||||| 82803|EAP|0300|ARTERIAL BLOOD GASES|Aenta Medicare Advantage|AETNA MEDICARE MA|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|United Healthcare|TML GROUP BENEFITS|741.25||||||| 82803|EAP|0300|ARTERIAL BLOOD GASES|Workers Compensation|UT EMPLOYEE INJURY|741.25||||||| 82803|EAP|0300|ARTERIAL BLOOD GASES|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|741.25||||||| 82803|EAP|0300|CORD BLOOD GAS|United Healthcare|UNITED HEALTHCARE|370.75||||||| 82803|EAP|0300|CAPILLARY BLOOD GAS|United Healthcare|UNITED HEALTHCARE OTHER|||||741.25||| 82803|EAP|0300|ARTERIAL BLOOD GASES|United Healthcare|UNITED HEALTHCARE OTHER|||||741.25||| 82803|EAP|0300|ARTERIAL BLOOD GASES|Veterans Affairs|VETERANS ADMINISTRATION|||||741.25||| 82803|EAP|0300|CAPILLARY BLOOD GAS|Managed Medicaid|MEDICAID SUPERIOR|741.25||||741.25||| 82803|EAP|0300|ARTERIAL BLOOD GASES|Medicaid|COUNTY INDIGENT HEALTH OTHER|741.25||||||| 82803|EAP|0300|CORD BLOOD GAS|Managed Medicaid|MEDICAID AMERIGROUP|370.75||||||| 82803|EAP|0300|ARTERIAL BLOOD GASES|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||741.25||| 82803|EAP|0300|ARTERIAL BLOOD GASES|Blue Cross HMO Specialty|BCBSTX HMO|741.25||||741.25||| 82803|EAP|0300|ARTERIAL BLOOD GASES|Managed Medicaid|MEDICAID AMERIGROUP|741.25||||||| 82803|EAP|0300|ARTERIAL BLOOD GASES|Medicaid|MEDICAID|741.25||||741.25||| 82803|EAP|0300|ARTERIAL BLOOD GASES|Managed Medicare|HOSPICE OF EAST TEXAS|741.25||||||| 82803|EAP|0300|ARTERIAL BLOOD GASES|Managed Medicaid|MEDICAID UNITED HEALTHCARE|741.25||||741.25||| 82803|EAP|0300|CAPILLARY BLOOD GAS|Managed Medicaid|MEDICAID AMERIGROUP|741.25||||||| 82803|EAP|0300|ARTERIAL BLOOD GASES|Rusk State Hospital|RUSK STATE HOSP|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|Managed Medicare|HEALTHSPRING MA|741.25||||741.25||| 82803|EAP|0300|ARTERIAL BLOOD GASES|Medicare|MEDICARE ACUTE|741.25||||741.25||| 82803|EAP|0300|ARTERIAL BLOOD GASES|Tricare|TRICARE EAST REGION|||||741.25||| 82803|EAP|0300|CAPILLARY BLOOD GAS|Medicaid|MEDICAID|741.25||||741.25||| 82803|EAP|0300|ARTERIAL BLOOD GASES|Managed Medicaid|MEDICAID SUPERIOR|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|UTMB|UTMB CORRECTIONAL MANAGED CARE|741.25||||741.25||| 82803|EAP|0300|CAPILLARY BLOOD GAS|United Healthcare|UNITED HEALTHCARE|741.25||||||| 82803|EAP|0300|ARTERIAL BLOOD GASES|United Healthcare|UNITED HEALTHCARE|741.25||||||| 82945|EAP|0301|GLUCOSE,BODY FLUID|Medicare|MEDICARE ACUTE|150.25||||||| 82945|EAP|0301|GLUCOSE CSF|Managed Medicaid|MEDICAID UNITED HEALTHCARE|150.25||||150.25||| 82945|EAP|0301|GLUCOSE CSF|Managed Medicaid|MEDICAID AMERIGROUP|150.25||||||| 82945|EAP|0301|GLUCOSE,BODY FLUID|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|150.25||||||| 82945|EAP|0301|GLUCOSE CSF|Medicaid|MEDICAID|150.25||||150.25||| 82945|EAP|0301|GLUCOSE CSF|Managed Medicaid|MEDICAID SUPERIOR|150.25||||||| 82945|EAP|0301|GLUCOSE,BODY FLUID|Blue Cross PPO Specialty|BCBSTX OTHER|150.25||||||| 82945|EAP|0301|GLUCOSE,BODY FLUID|Humana Medicare Advantage|HUMANA MA|150.25||||||| 82945|EAP|0301|GLUCOSE CSF|Blue Cross PPO Specialty|BCBSTX PPO|150.25||||||| 82945|EAP|0301|GLUCOSE CSF|Blue Cross HMO Specialty|BCBSTX HMO|150.25||||||| 82945|EAP|0301|GLUCOSE,BODY FLUID|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|150.25||||||| 82947|EAP|0300|GLUCOSE|Blue Cross PPO Specialty|BCBSTX PPO|150.25||||92.63||| 82947|EAP|0300|GLUCOSE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.35||| 82947|EAP|0300|GLUCOSE|Blue Cross HMO Specialty|BCBSTX HMO|||||150.25||| 82947|EAP|0300|GLUCOSE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.35||| 82947|EAP|0300|GLUCOSE|United Healthcare|UNITED HEALTHCARE OTHER|150.25||||||| 82947|EAP|0300|GLUCOSE|Managed Medicaid|MEDICAID AMERIGROUP|150.25||||||| 82947|EAP|0300|GLUCOSE|Managed Medicaid|MEDICAID SUPERIOR|150.25||||92.63||| 82947|EAP|0300|GLUCOSE|Medicare|MEDICARE ACUTE|||||0.35||| 82947|EAP|0300|GLUCOSE|United Healthcare|UNITED HEALTHCARE|||||150.25||| 82947|EAP|0300|GLUCOSE|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||150.25||| 82947|EAP|0300|GLUCOSE|United Medicare Advantage|UHC MEDICARE GOLD MA|150.25||||||| 82947|EAP|0300|GLUCOSE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||150.25||| 82950|EAP|0300|GLUCOSE 1HR PP|NON CONTRACTED|COMMERCIAL OTHER 2|||||42.50||| 82950|EAP|0300|GLUCOSE 1HR PP|Managed Medicaid|MEDICAID AMERIGROUP|||||42.50||| 82950|EAP|0300|GLUCOSE 1HR PP|Managed Medicaid|MEDICAID SUPERIOR|1.82||||42.50||| 82950|EAP|0300|GLUCOSE 1HR PP|Tricare|TRICARE EAST REGION|||||42.50||| 82950|EAP|0300|GLUCOSE 1HR PP|United Healthcare|UNITED HEALTHCARE|||||42.50||| 82950|EAP|0300|GLUCOSE 1HR PP|Medicaid|MEDICAID|||||42.50||| 82950|EAP|0300|GLUCOSE 1HR PP|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||42.50||| 82950|EAP|0300|GLUCOSE 1HR PP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||42.50||| 82950|EAP|0300|GLUCOSE 1HR PP|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||42.50||| 82950|EAP|0300|GLUCOSE 1HR PP|Medicaid|MEDICAID HMO|||||42.50||| 82950|EAP|0300|GLUCOSE 1HR PP|United Healthcare|UNITED HEALTHCARE OTHER|||||42.50||| 82950|EAP|0300|GLUCOSE 1HR PP|NON CONTRACTED|COMMERCIAL OTHER 1|||||42.50||| 82950|EAP|0300|GLUCOSE 2 HR PP|Managed Medicaid|MEDICAID AMERIGROUP|||||42.50||| 82950|EAP|0300|GLUCOSE 1HR PP|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||42.50||| 82950|EAP|0300|GLUCOSE 1HR PP|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||42.50||| 82950|EAP|0300|GLUCOSE 2 HR PP|Blue Cross PPO Specialty|BCBSTX PPO|||||42.50||| 82950|EAP|0300|GLUCOSE 1HR PP|Blue Cross HMO Specialty|BCBSTX HMO|||||42.50||| 82950|EAP|0300|GLUCOSE 1HR PP|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||42.50||| 82950|EAP|0300|GLUCOSE 1HR PP|Blue Cross PPO Specialty|BCBSTX PPO|||||42.50||| 82950|EAP|0300|GLUCOSE 1HR PP|Cigna|CIGNA|||||42.50||| 82950|EAP|0300|GLUCOSE 2 HR PP|Blue Cross HMO Specialty|BCBSTX HMO|||||42.50||| 82951|EAP|0301|GLUCOSE TOLERANCE (82951)|Blue Cross PPO Specialty|BCBSTX PPO|||||1.15||| 82951|EAP|0301|GLUCOSE TOLERANCE (82951)|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.15||| 82951|EAP|0301|GLUCOSE TOLERANCE (82951)|United Healthcare|UNITED HEALTHCARE OTHER|||||1.15||| 82951|EAP|0301|GLUCOSE TOLERANCE (82951)|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1.15||| 82951|EAP|0301|GLUCOSE TOLERANCE (82951)|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.15||| 82951|EAP|0301|GLUCOSE TOLERANCE (82951)|NON CONTRACTED|COMMERCIAL OTHER 1|||||1.15||| 82951|EAP|0301|GLUCOSE TOLERANCE (82951)|Medicaid|MEDICAID|||||1.15||| 82951|EAP|0301|GLUCOSE TOLERANCE (82951)|Managed Medicaid|MEDICAID SUPERIOR|||||1.15||| 82951|EAP|0301|GLUCOSE TOLERANCE (82951)|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||1.15||| 82951|EAP|0301|GLUCOSE TOLERANCE (82951)|Managed Medicaid|MEDICAID AMERIGROUP|||||1.15||| 82951|EAP|0301|GLUCOSE TOLERANCE (82951)|Blue Cross HMO Specialty|BCBSTX HMO|||||1.15||| 82951|EAP|0301|GLUCOSE TOLERANCE (82951)|Cigna|CIGNA|||||1.15||| 82952|EAP|0301|GLUCOSE TOLERANCE >3 SPEC|Managed Medicaid|MEDICAID AMERIGROUP|||||1.50||| 82952|EAP|0301|GLUCOSE TOLERANCE >3 SPEC|Managed Medicaid|MEDICAID SUPERIOR|||||1.50||| 82962|EAP|0301|GLUCOSE, POC|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|United Healthcare|UNITED HEALTHCARE|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|United Healthcare|UNITED HEALTHCARE|89.75||||||| 82962|EAP|0301|GLUCOSE, POC|United Healthcare|TML GROUP BENEFITS|89.75||||||| 82962|EAP|0301|GLUCOSE, POC|United Healthcare|UNITED HEALTHCARE OTHER|89.75||||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|Workers Compensation|WORKERS COMPENSATION OTHER|89.75||||||| 82962|EAP|0301|GLUCOSE, POC|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|89.75||||||| 82962|EAP|0301|GLUCOSE, POC|Blue Cross HMO Specialty|BCBSTX HMO|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|Veterans Affairs|VETERANS ADMINISTRATION|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Aenta Medicare Advantage|AETNA MEDICARE MA|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|89.75||||||| 82962|EAP|0301|GLUCOSE, POC|Aetna|AETNA PPO|89.75||||||| 82962|EAP|0301|GLUCOSE, POC|Cigna|CIGNA|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|89.75||||||| 82962|EAP|0301|GLUCOSE, POC|Brinson Benefits|THE HEALTH PLAN SMITH CO|89.75||||||| 82962|EAP|0301|GLUCOSE, POC|Blue Cross PPO Specialty|BCBSTX PPO|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Blue Cross PPO Specialty|BCBSTX OTHER|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Tricare|TRICARE EAST REGION|89.75||||||| 82962|EAP|0301|GLUCOSE, POC|NON CONTRACTED|COMMERCIAL OTHER 1|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|UTMB|UTMB CORRECTIONAL MANAGED CARE|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||89.75||| 82962|EAP|0301|GLUCOSE, POC|United Healthcare|UMR UNITED MEDICAL RESOURCES|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Workers Compensation|UT EMPLOYEE INJURY|89.75||||||| 82962|EAP|0301|GLUCOSE, POC|United Medicare Advantage|UHC MEDICARE GOLD MA|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Rusk State Hospital|RUSK STATE HOSP|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Medicare|MEDICARE PART B ONLY IP|89.75||||||| 82962|EAP|0301|GLUCOSE, POC|Managed Medicare|HOSPICE OF EAST TEXAS|89.75||||||| 82962|EAP|0300|CLINIC-BLOOD SUGAR-GLUCOM|Managed Medicaid|MEDICAID SUPERIOR|||||25.25||| 82962|EAP|0301|GLUCOSE, POC|Managed Medicaid|MEDICAID SUPERIOR|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Humana Medicare Advantage|HUMANA MA|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Managed Medicare|BCBS MEDICARE PPO MA|||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Medicare|MEDICARE ACUTE|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Medicaid|MEDICAID|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Managed Medicare|HEALTHSPRING MA|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|89.75||||89.75||| 82962|EAP|0301|GLUCOSE, POC|Managed Medicaid|MEDICAID AMERIGROUP|89.75||||89.75||| 82977|EAP|0301|GAMMA GLUTAMY TRANSFERASE|Managed Medicaid|MEDICAID AMERIGROUP|||||64.25||| 82977|EAP|0301|GAMMA GLUTAMY TRANSFERASE|Managed Medicaid|MEDICAID SUPERIOR|||||64.25||| 82977|EAP|0301|GAMMA GLUTAMY TRANSFERASE|Managed Medicare|HEALTHSPRING MA|||||64.25||| 82977|EAP|0301|GAMMA GLUTAMY TRANSFERASE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||64.25||| 82977|EAP|0301|GAMMA GLUTAMY TRANSFERASE|Medicaid|MEDICAID|||||64.25||| 82977|EAP|0301|GAMMA GLUTAMY TRANSFERASE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||64.25||| 82977|EAP|0301|GAMMA GLUTAMY TRANSFERASE|NON CONTRACTED|COMMERCIAL OTHER 1|||||64.25||| 82977|EAP|0301|GAMMA GLUTAMY TRANSFERASE|Medicare|MEDICARE ACUTE|64.25||||64.25||| 82977|EAP|0300|GGT|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.92||| 82977|EAP|0301|GAMMA GLUTAMY TRANSFERASE|Blue Cross PPO Specialty|BCBSTX PPO|||||64.25||| 82977|EAP|0301|GAMMA GLUTAMY TRANSFERASE|Blue Cross PPO Specialty|BCBSTX OTHER|||||64.25||| 82977|EAP|0301|GAMMA GLUTAMY TRANSFERASE|Humana Medicare Advantage|HUMANA MA|275.75||||64.25||| 82977|EAP|0301|GAMMA GLUTAMY TRANSFERASE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||64.25||| 82977|EAP|0301|GAMMA GLUTAMY TRANSFERASE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||64.25||| 82977|EAP|0301|GAMMA GLUTAMY TRANSFERASE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||64.25||| 82977|EAP|0301|GAMMA GLUTAMY TRANSFERASE|Blue Cross HMO Specialty|BCBSTX HMO|||||64.25||| 82977|EAP|0301|GAMMA GLUTAMY TRANSFERASE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||64.25||| 82977|EAP|0301|GAMMA GLUTAMY TRANSFERASE|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||275.75||| 82977|EAP|0301|GAMMA GLUTAMY TRANSFERASE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||64.25||| 82977|EAP|0301|GAMMA GLUTAMY TRANSFERASE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||64.25||| 82977|EAP|0301|GAMMA GLUTAMY TRANSFERASE|United Healthcare|UNITED HEALTHCARE|||||64.25||| 83001|EAP|0300|FOLLICLE STIMULATING HORM|United Healthcare|TML GROUP BENEFITS|||||1.66||| 83001|EAP|0300|FOLLICLE STIMULATING HORM|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||1.66||| 83001|EAP|0300|FOLLICLE STIMULATING HORM|Blue Cross HMO Specialty|BCBSTX HMO|||||1.66||| 83001|EAP|0300|FOLLICLE STIMULATING HORM|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||1.66||| 83001|EAP|0300|FOLLICLE STIMULATING HORM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.66||| 83001|EAP|0300|FOLLICLE STIMULATING HORM|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1.66||| 83001|EAP|0300|FOLLICLE STIMULATING HORM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.66||| 83001|EAP|0300|FOLLICLE STIMULATING HORM|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1.66||| 83001|EAP|0300|FOLLICLE STIMULATING HORM|Blue Cross PPO Specialty|BCBSTX PPO|||||1.66||| 83001|EAP|0300|FOLLICLE STIMULATING HORM|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.66||| 83001|EAP|0300|FOLLICLE STIMULATING HORM|Tricare|TRICARE EAST REGION|||||1.66||| 83001|EAP|0300|FOLLICLE STIMULATING HORM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1.66||| 83001|EAP|0300|FOLLICLE STIMULATING HORM|Managed Medicaid|MEDICAID AMERIGROUP|||||1.66||| 83001|EAP|0300|FOLLICLE STIMULATING HORM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1.66||| 83001|EAP|0300|FOLLICLE STIMULATING HORM|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.66||| 83001|EAP|0300|FOLLICLE STIMULATING HORM|Medicare|MEDICARE ACUTE|||||1.66||| 83001|EAP|0300|FOLLICLE STIMULATING HORM|NON CONTRACTED|COMMERCIAL OTHER 1|||||1.66||| 83001|EAP|0300|FOLLICLE STIMULATING HORM|Humana Medicare Advantage|HUMANA MA|||||1.66||| 83001|EAP|0300|FOLLICLE STIMULATING HORM|Blue Cross PPO Specialty|BCBSTX OTHER|||||1.66||| 83001|EAP|0300|FOLLICLE STIMULATING HORM|Managed Medicaid|MEDICAID SUPERIOR|||||1.66||| 83001|EAP|0300|FOLLICLE STIMULATING HORM|Cigna|CIGNA|||||1.66||| 83002|EAP|0300|LUTENINIZING HORMONE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||165.50||| 83002|EAP|0300|LUTENINIZING HORMONE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||165.50||| 83002|EAP|0300|LUTENINIZING HORMONE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||165.50||| 83002|EAP|0300|LUTENINIZING HORMONE|Managed Medicaid|MEDICAID AMERIGROUP|||||165.50||| 83002|EAP|0300|LUTENINIZING HORMONE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||165.50||| 83002|EAP|0300|LUTENINIZING HORMONE|Tricare|TRICARE EAST REGION|||||165.50||| 83002|EAP|0300|LUTENINIZING HORMONE|Managed Medicaid|MEDICAID SUPERIOR|||||165.50||| 83002|EAP|0300|LUTENINIZING HORMONE|NON CONTRACTED|COMMERCIAL OTHER 1|||||165.50||| 83002|EAP|0300|LUTENINIZING HORMONE|Medicare|MEDICARE ACUTE|||||165.50||| 83002|EAP|0300|LUTENINIZING HORMONE|Blue Cross PPO Specialty|BCBSTX PPO|||||165.50||| 83002|EAP|0300|LUTENINIZING HORMONE|Humana Medicare Advantage|HUMANA MA|||||165.50||| 83002|EAP|0300|LUTENINIZING HORMONE|Cigna|CIGNA|||||165.50||| 83002|EAP|0300|LUTENINIZING HORMONE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||165.50||| 83002|EAP|0300|LUTENINIZING HORMONE|Blue Cross HMO Specialty|BCBSTX HMO|||||165.50||| 83002|EAP|0300|LUTENINIZING HORMONE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||165.50||| 83002|EAP|0300|LUTENINIZING HORMONE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||165.50||| 83002|EAP|0300|LUTENINIZING HORMONE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||165.50||| 83002|EAP|0300|LUTENINIZING HORMONE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||165.50||| 83002|EAP|0300|LUTENINIZING HORMONE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||165.50||| 83002|EAP|0300|LUTENINIZING HORMONE|United Healthcare|UNITED HEALTHCARE|||||165.50||| 83002|EAP|0300|LUTENINIZING HORMONE|United Healthcare|TML GROUP BENEFITS|||||165.50||| 83003|EAP|0301|GROWTH HORMONE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1.49||| 83003|EAP|0301|GROWTH HORMONE|Medicare|MEDICARE ACUTE|||||1.49||| 83003|EAP|0301|GROWTH HORMONE|Managed Medicaid|MEDICAID AMERIGROUP|||||1.49||| 83003|EAP|0301|GROWTH HORMONE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1.49||| 83003|EAP|0301|GROWTH HORMONE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.49||| 83010|EAP|0301|HAPTOGLOBIN|Blue Cross HMO Specialty|BCBSTX HMO|4.82||||4.82||| 83010|EAP|0301|HAPTOGLOBIN|Medicare|MEDICARE ACUTE|4.82||||||| 83010|EAP|0301|HAPTOGLOBIN|Managed Medicaid|MEDICAID AMERIGROUP|||||4.82||| 83015|EAP|0301|HEAVY METALS BLOOD|Blue Cross PPO Specialty|BCBSTX PPO|||||168.25||| 83015|EAP|0301|HEAVY METALS BLOOD|Medicare|MEDICARE ACUTE|||||168.25||| 83018|EAP|0301|HEAVY METALS,URINE,24HR|NON CONTRACTED|COMMERCIAL OTHER 1|||||196.25||| 83020|EAP|0301|HEMOGLOBIN ELECTROPHORESI|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.15||| 83020|EAP|0301|HEMOGLOBIN ELECTROPHORESI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.15||| 83020|EAP|0301|HEMOGLOBIN ELECTROPHORESI|Blue Cross PPO Specialty|BCBSTX PPO|||||1.15||| 83020|EAP|0301|HEMOGLOBIN ELECTROPHORESI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1.15||| 83020|EAP|0301|HEMOGLOBIN ELECTROPHORESI|Managed Medicaid|MEDICAID SUPERIOR|||||1.15||| 83020|EAP|0301|HEMOGLOBIN ELECTROPHORESI|Medicare|MEDICARE ACUTE|||||1.15||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Medicare|MEDICARE PART B ONLY IP|371.75||||86.75||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|UTMB|UTMB CORRECTIONAL MANAGED CARE|371.75||||371.75||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|NON CONTRACTED|COMMERCIAL OTHER 1|371.75||||86.75||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Medicare|MEDICARE ACUTE|371.75||||86.75||| 83036|EAP|0300|GLYCOHEMOGLOBIN A1C/W/MEA|Medicare|MEDICARE ACUTE|||||86.75||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||86.75||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Managed Medicare|BCBS MEDICARE PPO MA|||||86.75||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|371.75||||86.75||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Medicaid|MEDICAID|371.75||||86.75||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Tricare|TRICARE EAST REGION|||||86.75||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||86.75||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Medicaid|MEDICAID HMO|||||86.75||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Managed Medicaid|MEDICAID AMERIGROUP|371.75||||86.75||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Medicaid|MEDICAID TEXAS CHILDRENS|||||86.75||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|371.75||||86.75||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Cigna|CIGNA|||||86.75||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Blue Cross PPO Specialty|BCBSTX PPO|371.75||||86.75||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Rusk State Hospital|RUSK STATE HOSP|371.75||||86.75||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Blue Cross PPO Specialty|BCBSTX OTHER|371.75||||86.75||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||86.75||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||86.75||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||86.75||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Aetna|BOON CHAPMAN|||||86.75||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|371.75||||86.75||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Humana Medicare Advantage|HUMANA MA|371.75||||86.75||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||86.75||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Managed Medicaid|MEDICAID SUPERIOR|371.75||||86.75||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Aenta Medicare Advantage|AETNA MEDICARE MA|371.75||||86.75||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Aetna|AETNA PPO|371.75||||86.75||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||86.75||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Blue Cross HMO Specialty|BCBSTX HMO|371.75||||86.75||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Managed Medicare|HEALTHSPRING MA|||||86.75||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|371.75||||86.75||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Workers Compensation|UT EMPLOYEE INJURY|371.75||||||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|371.75||||86.75||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|United Healthcare|UNITED HEALTHCARE|371.75||||86.75||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||86.75||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|PHCS|HUMANA INSURANCE|||||86.75||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|United Medicare Advantage|UHC MEDICARE GOLD MA|371.75||||86.75||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|United Medicare Advantage|AARP UHC WEST COMPLETE MA|371.75||||86.75||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|United Healthcare|UNITED HEALTHCARE OTHER|||||86.75||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|United Healthcare|UNITED HEALTHCARE|||||86.75||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||86.75||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|United Healthcare|TML GROUP BENEFITS|371.75||||86.75||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Veterans Affairs|VETERANS ADMINISTRATION|||||229.25||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|371.75||||||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|United Healthcare|GEHA|||||86.75||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Workers Compensation|WORKERS COMPENSATION OTHER|371.75||||371.75||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|Aetna|AETNA OTHER|||||86.75||| 83036|EAP|0301|HEMOGLOBIN AIC W/MEAN PLA|United Healthcare|AARP|||||86.75||| 83037|EAP|0300|CLINIC-HEMOGLOBIN W/DEVIC|Medicaid|MEDICAID|||||0.33||| 83037|EAP|0300|CLINIC-HEMOGLOBIN W/DEVIC|Medicare|MEDICARE ACUTE|||||0.33||| 83090|EAP|0301|HOMOCYSTEINE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||150.75||| 83090|EAP|0301|HOMOCYSTEINE|Blue Cross PPO Specialty|BCBSTX PPO|||||150.75||| 83090|EAP|0301|HOMOCYSTEINE|Tricare|TRICARE EAST REGION|||||150.75||| 83090|EAP|0301|HOMOCYSTEINE|Managed Medicaid|MEDICAID AMERIGROUP|||||150.75||| 83090|EAP|0301|HOMOCYSTEINE|Medicare|MEDICARE ACUTE|||||150.75||| 83090|EAP|0301|HOMOCYSTEINE|Managed Medicaid|MEDICAID SUPERIOR|646.25||||150.75||| 831|DRG||OTHER ANTEPARTUM DIAGNOSES W/O O.R. PROCEDURE W MCC|Managed Medicaid|MEDICAID SUPERIOR|35,195.95|8985.27|8985.27|8985.27|||| 832|DRG||OTHER ANTEPARTUM DIAGNOSES W/O O.R. PROCEDURE W CC|Medicaid|MEDICAID|23,429.50|4680.94|7442.69|4680.94|||| 832|DRG||OTHER ANTEPARTUM DIAGNOSES W/O O.R. PROCEDURE W CC|Managed Medicaid|MEDICAID SUPERIOR|15,552.30|7442.69|7442.69|4680.94|||| 833|DRG||OTHER ANTEPARTUM DIAGNOSES W/O O.R. PROCEDURE W/O CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|10,500.63|563.87|10812.75|563.87|||| 833|DRG||OTHER ANTEPARTUM DIAGNOSES W/O O.R. PROCEDURE W/O CC/MCC|Managed Medicaid|MEDICAID AMERIGROUP|162.10|7442.69|10812.75|563.87|||| 833|DRG||OTHER ANTEPARTUM DIAGNOSES W/O O.R. PROCEDURE W/O CC/MCC|Managed Medicaid|MEDICAID SUPERIOR|12,368.15|5628.68|10812.75|563.87|||| 833|DRG||OTHER ANTEPARTUM DIAGNOSES W/O O.R. PROCEDURE W/O CC/MCC|NON CONTRACTED|COMMERCIAL OTHER 2|10,812.75|10812.75|10812.75|563.87|||| 833|DRG||OTHER ANTEPARTUM DIAGNOSES W/O O.R. PROCEDURE W/O CC/MCC|Medicaid|SUPERIOR HEALTHPLAN CHIP|145.65|4680.94|10812.75|563.87|||| 83498|EAP|0301|17 ALPHA HYDROXYPROGESTER|Managed Medicaid|MEDICAID SUPERIOR|||||242.75||| 83498|EAP|0301|17 ALPHA HYDROXYPROGESTER|Blue Cross HMO Specialty|BCBSTX HMO|||||242.75||| 83498|EAP|0301|17 ALPHA HYDROXYPROGESTER|Blue Cross PPO Specialty|BCBSTX PPO|1,040.75||||||| 83516|EAP|0300|MITOCHONDRIAL ANTIBODY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||107.75||| 83516|EAP|0301|ACETYLOCHOLINE RECEPTOR M|Blue Cross HMO Specialty|BCBSTX HMO|||||205.50||| 83516|EAP|0300|IMMUNOASSAY ANALYTE IAAB/|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||395.25||| 83516|EAP|0300|MITOCHONDRIAL ANTIBODY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||107.75||| 83516|EAP|0300|IMMUNOASSAY ANALYTE IAAB/|Blue Cross HMO Specialty|BCBSTX HMO|||||395.25||| 83516|EAP|0301|ACETYLOCHOLINE RECEPTOR B|Blue Cross HMO Specialty|BCBSTX HMO|||||120.75||| 83516|EAP|0300|MITOCHONDRIAL ANTIBODY|Humana Medicare Advantage|HUMANA MA|||||107.75||| 83516|EAP|0300|MITOCHONDRIAL ANTIBODY|Blue Cross PPO Specialty|BCBSTX PPO|||||107.75||| 83516|EAP|0301|TISSUE TRANSGLUTAMINASE I|Blue Cross PPO Specialty|BCBSTX PPO|||||1.03||| 83516|EAP|0300|GAD 65 ANTIBODY|Blue Cross PPO Specialty|BCBSTX PPO|||||2.01||| 83516|EAP|0300|MITOCHONDRIAL ANTIBODY|Blue Cross HMO Specialty|BCBSTX HMO|||||107.75||| 83516|EAP|0301|ANTI TISSUE TRANSGLUTAMIN|Blue Cross PPO Specialty|BCBSTX PPO|||||98.75||| 83516|EAP|0300|IMMUNOASSAY ANALYTE IAAB/|Humana Medicare Advantage|HUMANA MA|||||395.25||| 83516|EAP|0300|IMMUNOASSAY ANALYTE IAAB/|Blue Cross PPO Specialty|BCBSTX PPO|||||395.25||| 83516|EAP|0300|IMMUNOASSAY ANALYTE IAAB/|United Healthcare|UNITED HEALTHCARE|||||1,426.25||| 83516|EAP|0301|ACETYLOCHOLINE RECEPTOR M|Medicare|MEDICARE ACUTE|||||205.50||| 83516|EAP|0301|ACETYLOCHOLINE RECEPTOR B|Medicare|MEDICARE ACUTE|||||120.75||| 83516|EAP|0300|MITOCHONDRIAL ANTIBODY|NON CONTRACTED|COMMERCIAL OTHER 1|||||107.75||| 83516|EAP|0300|MITOCHONDRIAL ANTIBODY|Medicare|MEDICARE ACUTE|107.75||||107.75||| 83516|EAP|0300|GLOMERULAR BASEMENT MEMB|Medicare|MEDICARE ACUTE|107.75||||115.75||| 83516|EAP|0301|ACETYLOCHOLINE RECEPTOR B|Medicaid|MEDICAID|5.18||||||| 83516|EAP|0300|MITOCHONDRIAL ANTIBODY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||107.75||| 83516|EAP|0301|ANTI TISSUE TRANSGLUTAMIN|Managed Medicaid|MEDICAID AMERIGROUP|||||98.75||| 83516|EAP|0301|TISSUE TRANSGLUTAMINASE I|Managed Medicaid|MEDICAID AMERIGROUP|||||1.03||| 83516|EAP|0300|IMMUNOASSAY ANALYTE IAAB/|Managed Medicaid|MEDICAID SUPERIOR|||||395.25||| 83516|EAP|0300|GAD 65 ANTIBODY|Medicaid|MEDICAID|||||2.01||| 83516|EAP|0300|IMMUNOASSAY ANALYTE IAAB/|Medicaid|MEDICAID TEXAS CHILDRENS|||||395.25||| 83516|EAP|0300|MITOCHONDRIAL ANTIBODY|Managed Medicaid|MEDICAID SUPERIOR|||||107.75||| 83516|EAP|0300|IMMUNOASSAY ANALYTE IAAB/|Managed Medicaid|MEDICAID AMERIGROUP|||||395.25||| 83516|EAP|0300|IMMUNOASSAY ANALYTE IAAB/|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||395.25||| 83516|EAP|0300|MITOCHONDRIAL ANTIBODY|Medicaid|MEDICAID|||||107.75||| 83516|EAP|0300|IMMUNOASSAY ANALYTE IAAB/|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||395.25||| 83516|EAP|0301|TISSUE TRANSGLUTAMINASE I|Managed Medicaid|MEDICAID SUPERIOR|||||1.03||| 83516|EAP|0301|ANTI TISSUE TRANSGLUTAMIN|Managed Medicaid|MEDICAID SUPERIOR|||||98.75||| 83519|EAP|0301|ACETYLOCHOLINE RECEPTOR B|Medicaid|MEDICAID|5.18||||||| 83519|EAP|0301|ACETYLOCHOLINE RECEPTOR B|Medicare|MEDICARE ACUTE|||||120.75||| 83519|EAP|0301|ACETYLOCHOLINE RECEPTOR B|Humana Medicare Advantage|HUMANA MA|||||120.75||| 83519|EAP|0301|ACETYLOCHOLINE RECEPTOR B|Blue Cross HMO Specialty|BCBSTX HMO|||||120.75||| 83520|EAP|0300|FECAL ELASTASE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||113.75||| 83520|EAP|0300|FECAL ELASTASE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||113.75||| 83520|EAP|0300|THYROTROPIN RECEPTOR ANTI|United Medicare Advantage|UHC MEDICARE GOLD MA|||||467.75||| 83520|EAP|0300|FECAL ELASTASE|Blue Cross HMO Specialty|BCBSTX HMO|||||113.75||| 83520|EAP|0300|PARANEOPLASTIC STRIATIONA|Humana Medicare Advantage|HUMANA MA|||||113.75||| 83520|EAP|0300|FECAL ELASTASE|Blue Cross PPO Specialty|BCBSTX PPO|||||113.75||| 83520|EAP|0300|THYROTROPIN RECEPTOR ANTI|Blue Cross PPO Specialty|BCBSTX PPO|||||467.75||| 83520|EAP|0300|THYROTROPIN RECEPTOR ANTI|Humana Medicare Advantage|HUMANA MA|||||467.75||| 83520|EAP|0300|THYROTROPIN RECEPTOR ANTI|Medicare|MEDICARE ACUTE|||||467.75||| 83520|EAP|0300|FECAL ELASTASE|Medicare|MEDICARE ACUTE|||||113.75||| 83520|EAP|0300|THYROTROPIN RECEPTOR ANTI|Managed Medicaid|MEDICAID SUPERIOR|||||467.75||| 83520|EAP|0300|THYROTROPIN RECEPTOR ANTI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||467.75||| 83520|EAP|0300|FECAL ELASTASE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||113.75||| 83520|EAP|0300|FECAL ELASTASE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||113.75||| 83520|EAP|0301|IMMUNOASSY NOT OTHERWISE|Medicare|MEDICARE ACUTE|496.25||||||| 83520|EAP|0300|THYROTROPIN RECEPTOR ANTI|Managed Medicaid|MEDICAID AMERIGROUP|||||467.75||| 83520|EAP|0300|FECAL ELASTASE|Managed Medicaid|MEDICAID AMERIGROUP|||||113.75||| 83520|EAP|0300|FECAL ELASTASE|Humana Medicare Advantage|HUMANA MA|||||113.75||| 83520|EAP|0300|THYROTROPIN RECEPTOR ANTI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||467.75||| 83520|EAP|0301|HISTONE ANTIBODY BY ELISA|Managed Medicaid|MEDICAID AMERIGROUP|||||115.75||| 83525|EAP|0301|INSULIN LEVEL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||102.25||| 83525|EAP|0301|INSULIN LEVEL|Medicaid|MEDICAID|||||64.25||| 83525|EAP|0301|INSULIN LEVEL|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||102.25||| 83525|EAP|0301|INSULIN LEVEL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||102.25||| 83525|EAP|0301|INSULIN LEVEL|Managed Medicaid|MEDICAID SUPERIOR|||||102.25||| 83525|EAP|0301|INSULIN LEVEL|Managed Medicaid|MEDICAID AMERIGROUP|||||26.25||| 83525|EAP|0301|INSULIN LEVEL|Medicare|MEDICARE ACUTE|437.75||||102.25||| 83525|EAP|0301|INSULIN LEVEL|Humana Medicare Advantage|HUMANA MA|||||102.25||| 83525|EAP|0301|INSULIN LEVEL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||102.25||| 83525|EAP|0301|INSULIN LEVEL|Blue Cross PPO Specialty|BCBSTX PPO|||||102.25||| 83525|EAP|0301|INSULIN LEVEL|Cigna|CIGNA|||||102.25||| 83525|EAP|0301|INSULIN LEVEL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||102.25||| 83525|EAP|0301|INSULIN LEVEL|Blue Cross HMO Specialty|BCBSTX HMO|||||102.25||| 83525|EAP|0301|INSULIN LEVEL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||102.25||| 83525|EAP|0301|INSULIN LEVEL|United Healthcare|UNITED HEALTHCARE OTHER|||||102.25||| 83525|EAP|0301|INSULIN LEVEL|United Healthcare|TML GROUP BENEFITS|||||102.25||| 83525|EAP|0301|INSULIN LEVEL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||102.25||| 83525|EAP|0301|INSULIN LEVEL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||102.25||| 83525|EAP|0301|INSULIN LEVEL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||102.25||| 83527|EAP|0300|INSULIN FREE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||115.75||| 83527|EAP|0300|INSULIN FREE|Medicare|MEDICARE ACUTE|||||115.75||| 83527|EAP|0300|INSULIN FREE|Cigna|CIGNA|||||115.75||| 83540|EAP|0301|IRON|Managed Medicaid|MEDICAID AMERIGROUP|||||2.48||| 83540|EAP|0301|IRON|Medicaid|MEDICAID|2.48||||2.48||| 83540|EAP|0301|IRON|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.58||| 83540|EAP|0301|IRON|Managed Medicaid|MEDICAID SUPERIOR|||||0.58||| 83540|EAP|0301|IRON|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.58||| 83540|EAP|0301|IRON|United Medicare Advantage|UHC MEDICARE GOLD MA|2.48||||0.58||| 83540|EAP|0301|IRON|Blue Cross PPO Specialty|BCBSTX OTHER|||||2.48||| 83540|EAP|0301|IRON|Humana Medicare Advantage|HUMANA MA|2.48||||0.58||| 83540|EAP|0301|IRON|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.58||| 83540|EAP|0301|IRON|Tricare|TRICARE EAST REGION|||||0.58||| 83540|EAP|0301|IRON|Medicare|MEDICARE ACUTE|2.48||||1.53||| 83540|EAP|0301|IRON|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.58||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Workers Compensation|WORKERS COMPENSATION OTHER|335.25||||0.78||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||0.78||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|United Medicare Advantage|UHC MEDICARE GOLD MA|335.25||||0.78||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.78||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|United Healthcare|UNITED HEALTHCARE OTHER|||||0.78||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|United Healthcare|UNITED HEALTHCARE|||||0.78||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Humana Medicare Advantage|HUMANA MA|||||0.78||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Brinson Benefits|THE HEALTH PLAN SMITH CO|335.25||||||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||0.78||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Blue Cross PPO Specialty|BCBSTX PPO|335.25||||0.78||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|335.25||||0.78||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Aenta Medicare Advantage|AETNA MEDICARE MA|||||0.78||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.78||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||0.78||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.78||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Access Direct Platinum|HEALTHFIRST TPA UMR|||||0.78||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Aetna|AETNA PPO|||||0.78||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.78||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Cigna|CIGNA|||||0.78||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|PHCS|HUMANA INSURANCE|||||0.78||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||0.78||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|UTMB|UTMB CORRECTIONAL MANAGED CARE|335.25||||||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Medicare|MEDICARE ACUTE|335.25||||0.78||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.78||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||0.78||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.78||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.78||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Managed Medicaid|MEDICAID AMERIGROUP|||||0.78||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Managed Medicaid|MEDICAID SUPERIOR|335.25||||0.78||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.78||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|335.25||||0.78||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Medicaid|MEDICAID HMO|||||0.78||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Tricare|TRICARE EAST REGION|||||0.78||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Blue Cross HMO Specialty|BCBSTX HMO|335.25||||0.78||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Medicaid|MEDICAID|||||0.78||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Medicaid|MEDICAID TEXAS CHILDRENS|||||0.78||| 83550|EAP|0300|TOTAL IRON BINDING UIBC|Managed Medicare|HEALTHSPRING MA|335.25||||0.78||| 83605|EAP|0301|LACTIC ACID|Medicaid|COUNTY INDIGENT HEALTH OTHER|409.25||||409.25||| 83605|EAP|0301|LACTIC ACID|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|409.25||||||| 83605|EAP|0301|LACTIC ACID|Managed Medicare|HOSPICE OF EAST TEXAS|409.25||||||| 83605|EAP|0301|LACTIC ACID|Medicaid|MEDICAID TEXAS CHILDRENS|||||409.25||| 83605|EAP|0301|LACTIC ACID|Medicaid|MEDICAID|409.25||||409.25||| 83605|EAP|0301|LACTIC ACID|Managed Medicaid|MEDICAID UNITED HEALTHCARE|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 CIGNA HEALTHSPRING|409.25||||409.25||| 83605|EAP|0301|LACTIC ACID|Managed Medicaid|MEDICAID AMERIGROUP|409.25||||409.25||| 83605|EAP|0301|LACTIC ACID|Medicare|MEDICARE ACUTE|409.25||||409.25||| 83605|EAP|0301|LACTIC ACID|Tricare|TRICARE EAST REGION|||||409.25||| 83605|EAP|0301|LACTIC ACID|NON CONTRACTED|COMMERCIAL OTHER 1|409.25||||409.25||| 83605|EAP|0301|LACTIC ACID|UTMB|UTMB CORRECTIONAL MANAGED CARE|409.25||||409.25||| 83605|EAP|0301|LACTIC ACID|Rusk State Hospital|RUSK STATE HOSP|409.25||||409.25||| 83605|EAP|0301|LACTIC ACID|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||409.25||| 83605|EAP|0301|LACTIC ACID|Aenta Medicare Advantage|AETNA MEDICARE MA|409.25||||409.25||| 83605|EAP|0301|LACTIC ACID|Medicaid|MEDICAID HMO|||||409.25||| 83605|EAP|0301|LACTIC ACID|Aetna|AETNA OTHER|409.25||||||| 83605|EAP|0301|LACTIC ACID|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|409.25||||409.25||| 83605|EAP|0301|LACTIC ACID|Blue Cross HMO Specialty|BCBSTX HMO|409.25||||409.25||| 83605|EAP|0301|LACTIC ACID|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|409.25||||409.25||| 83605|EAP|0301|LACTIC ACID|Aetna|AETNA PPO|409.25||||409.25||| 83605|EAP|0301|LACTIC ACID|Brinson Benefits|THE HEALTH PLAN SMITH CO|409.25||||||| 83605|EAP|0301|LACTIC ACID|Humana Medicare Advantage|HUMANA MA|409.25||||409.25||| 83605|EAP|0301|LACTIC ACID|Blue Cross PPO Specialty|BCBSTX OTHER|409.25||||409.25||| 83605|EAP|0301|LACTIC ACID|Managed Medicare|HEALTHSPRING MA|409.25||||||| 83605|EAP|0301|LACTIC ACID|Blue Cross PPO Specialty|BCBSTX PPO|409.25||||409.25||| 83605|EAP|0301|LACTIC ACID|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|409.25||||409.25||| 83605|EAP|0301|LACTIC ACID|Cigna|CIGNA|||||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 Healthcare|UNITED HEALTHCARE|||||409.25||| 83605|EAP|0301|LACTIC ACID|United Healthcare|UMR UNITED MEDICAL RESOURCES|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|United Medicare Advantage|UHC MEDICARE GOLD MA|409.25||||409.25||| 83605|EAP|0301|LACTIC ACID|Veterans Affairs|VETERANS ADMINISTRATION|409.25||||409.25||| 83605|EAP|0301|LACTIC ACID|Workers Compensation|WORKERS COMPENSATION OTHER|409.25||||409.25||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|231.25||||0.54||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Workers Compensation|UT EMPLOYEE INJURY|231.25||||||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|United Healthcare|UNITED HEALTHCARE|||||0.54||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|United Medicare Advantage|UHC MEDICARE GOLD MA|231.25||||231.25||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|United Healthcare|UNITED HEALTHCARE|231.25||||231.25||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Workers Compensation|WORKERS COMPENSATION OTHER|231.25||||||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|United Medicare Advantage|AARP UHC WEST COMPLETE MA|231.25||||231.25||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Blue Cross PPO Specialty|BCBSTX OTHER|231.25||||0.54||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Cigna|CIGNA|||||0.54||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Cigna|CIGNA|||||231.25||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Humana Medicare Advantage|HUMANA MA|231.25||||0.54||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||231.25||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Blue Cross PPO Specialty|BCBSTX PPO|231.25||||0.54||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Blue Cross HMO Specialty|BCBSTX HMO|231.25||||231.25||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Aenta Medicare Advantage|AETNA MEDICARE MA|||||231.25||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.54||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Aetna|AETNA PPO|||||231.25||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|231.25||||||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|NON CONTRACTED|COMMERCIAL OTHER 1|231.25||||||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|UTMB|UTMB CORRECTIONAL MANAGED CARE|231.25||||231.25||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||231.25||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Medicare|MEDICARE ACUTE|231.25||||0.54||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Rusk State Hospital|RUSK STATE HOSP|231.25||||0.54||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Medicaid|MEDICAID|231.25||||0.54||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|231.25||||0.54||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Managed Medicaid|MEDICAID UNITED HEALTHCARE|231.25||||231.25||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Managed Medicare|HEALTHSPRING MA|||||0.54||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Managed Medicaid|MEDICAID SUPERIOR|||||231.25||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Medicaid|COUNTY INDIGENT HEALTH OTHER|231.25||||||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Managed Medicaid|MEDICAID AMERIGROUP|||||231.25||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Medicaid|SUPERIOR HEALTHPLAN CHIP|231.25||||231.25||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|231.25||||0.54||| 83615|EAP|0300|LACTATE DEHYDROGENASE LDH|Managed Medicare|HOSPICE OF EAST TEXAS|231.25||||||| 83630|EAP|0300|LACTOFERRIN (STOOL)|Managed Medicaid|MEDICAID SUPERIOR|||||175.50||| 83630|EAP|0300|LACTOFERRIN (STOOL)|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||175.50||| 83630|EAP|0300|LACTOFERRIN (STOOL)|Blue Cross PPO Specialty|BCBSTX PPO|||||175.50||| 83630|EAP|0300|LACTOFERRIN (STOOL)|Blue Cross PPO Specialty|BCBSTX OTHER|||||175.50||| 83630|EAP|0300|LACTOFERRIN (STOOL)|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||175.50||| 83655|EAP|0301|LEAD|Access Direct Platinum|HEALTHFIRST TPA UMR|||||108.25||| 83655|EAP|0301|LEAD|PHCS|HUMANA INSURANCE|||||108.25||| 83655|EAP|0301|LEAD|Medicaid|MEDICAID|||||108.25||| 83655|EAP|0301|LEAD|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||108.25||| 83655|EAP|0301|LEAD|Managed Medicaid|MEDICAID AMERIGROUP|||||108.25||| 83655|EAP|0301|LEAD|Managed Medicaid|MEDICAID SUPERIOR|||||108.25||| 83655|EAP|0301|LEAD|Medicare|MEDICARE ACUTE|||||108.25||| 83655|EAP|0301|LEAD|Blue Cross PPO Specialty|BCBSTX PPO|||||108.25||| 83655|EAP|0301|LEAD|NON CONTRACTED|COMMERCIAL OTHER 1|||||108.25||| 83690|EAP|0301|LIPASE|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||264.25||| 83690|EAP|0301|LIPASE|Medicaid|MEDICAID HMO|||||264.25||| 83690|EAP|0301|LIPASE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|264.25||||264.25||| 83690|EAP|0301|LIPASE|Managed Medicare|HOSPICE OF EAST TEXAS|264.25||||||| 83690|EAP|0301|LIPASE|Medicaid|MOLINA HEALTHCARE OF TEXAS|264.25||||264.25||| 83690|EAP|0301|LIPASE|Medicaid|MEDICAID|264.25||||264.25||| 83690|EAP|0301|LIPASE|Managed Medicaid|MEDICAID SUPERIOR|264.25||||264.25||| 83690|EAP|0301|LIPASE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|264.25||||264.25||| 83690|EAP|0301|LIPASE|Managed Medicaid|MEDICAID AMERIGROUP|264.25||||264.25||| 83690|EAP|0301|LIPASE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||264.25||| 83690|EAP|0301|LIPASE|Tricare|TRICARE EAST REGION|||||264.25||| 83690|EAP|0301|LIPASE|Rusk State Hospital|RUSK STATE HOSP|264.25||||264.25||| 83690|EAP|0301|LIPASE|UTMB|UTMB CORRECTIONAL MANAGED CARE|264.25||||264.25||| 83690|EAP|0301|LIPASE|United Healthcare|UNITED HEALTHCARE OTHER|||||162.88||| 83690|EAP|0301|LIPASE|United Healthcare|UNITED HEALTHCARE|264.25||||264.25||| 83690|EAP|0301|LIPASE|United Healthcare|UMR UNITED MEDICAL RESOURCES|264.25||||162.88||| 83690|EAP|0301|LIPASE|United Medicare Advantage|UHC MEDICARE GOLD MA|264.25||||264.25||| 83690|EAP|0301|LIPASE|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||162.88||| 83690|EAP|0301|LIPASE|United Medicare Advantage|AARP UHC WEST COMPLETE 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|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|Blue Cross PPO Specialty|BCBSTX PPO|264.25||||264.25||| 83690|EAP|0301|LIPASE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|264.25||||264.25||| 83690|EAP|0301|LIPASE|Medicaid|MEDICAID PCCM|||||264.25||| 83690|EAP|0301|LIPASE|Humana Medicare Advantage|HUMANA MA|264.25||||264.25||| 83690|EAP|0301|LIPASE|Cigna|CIGNA|264.25||||162.88||| 83690|EAP|0301|LIPASE|Managed Medicare|HEALTHSPRING MA|||||162.88||| 83690|EAP|0301|LIPASE|Cigna|CIGNA|||||264.25||| 83690|EAP|0301|LIPASE|Cigna|CIGNA|264.25||||||| 83690|EAP|0301|LIPASE|Medicare|MEDICARE ACUTE|264.25||||264.25||| 83690|EAP|0301|LIPASE|Blue Cross PPO Specialty|BCBSTX OTHER|||||264.25||| 83690|EAP|0301|LIPASE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||264.25||| 83690|EAP|0301|LIPASE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|264.25||||264.25||| 83690|EAP|0301|LIPASE|NON CONTRACTED|COMMERCIAL OTHER 1|264.25||||264.25||| 83690|EAP|0301|LIPASE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|264.25||||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 UHSS UT HLTH|264.25||||264.25||| 83690|EAP|0301|LIPASE|Aetna|AETNA OTHER|||||264.25||| 83721|EAP|0300|LDL, DIRECT|Blue Cross PPO Specialty|BCBSTX PPO|||||84.25||| 83721|EAP|0300|LDL, DIRECT|Medicare|MEDICARE ACUTE|||||84.25||| 83721|EAP|0300|LDL, DIRECT|Managed Medicaid|MEDICAID SUPERIOR|||||84.25||| 83735|EAP|0301|MAGNESIUM|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||2.57||| 83735|EAP|0301|MAGNESIUM|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.57||||0.60||| 83735|EAP|0301|MAGNESIUM|Managed Medicare|HEALTHSPRING MA|2.57||||0.60||| 83735|EAP|0301|MAGNESIUM|Managed Medicare|HOSPICE OF EAST TEXAS|2.57||||||| 83735|EAP|0301|MAGNESIUM|Medicaid|MEDICAID|2.57||||2.57||| 83735|EAP|0301|MAGNESIUM 24 HR URINE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.57||||0.60||| 83735|EAP|0301|MAGNESIUM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.57||||0.60||| 83735|EAP|0301|MAGNESIUM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.57||||0.60||| 83735|EAP|0301|MAGNESIUM|Medicaid|MEDICAID TEXAS CHILDRENS|||||0.60||| 83735|EAP|0301|MAGNESIUM|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||2.57||| 83735|EAP|0301|MAGNESIUM|PHCS|HUMANA INSURANCE|||||2.57||| 83735|EAP|0301|MAGNESIUM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.57||||2.57||| 83735|EAP|0301|MAGNESIUM|NON CONTRACTED|COMMERCIAL OTHER 1|2.57||||0.60||| 83735|EAP|0301|MAGNESIUM|Medicare|MEDICARE ACUTE|2.57||||2.57||| 83735|EAP|0301|MAGNESIUM|Rusk State Hospital|RUSK STATE HOSP|2.57||||||| 83735|EAP|0301|MAGNESIUM|NON CONTRACTED|COMMERCIAL OTHER 2|||||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|Workers Compensation|UT EMPLOYEE INJURY|2.57||||||| 83735|EAP|0301|MAGNESIUM|United Healthcare|UNITED HEALTHCARE OTHER|||||2.57||| 83735|EAP|0301|MAGNESIUM|United Healthcare|UNITED HEALTHCARE|2.57||||2.57||| 83735|EAP|0301|MAGNESIUM|Tricare|TRICARE EAST REGION|||||0.60||| 83735|EAP|0301|MAGNESIUM|United Healthcare|UNITED HEALTHCARE|2.57||||158.50||| 83735|EAP|0301|MAGNESIUM|United Healthcare|UMR UNITED MEDICAL RESOURCES|2.57||||2.57||| 83735|EAP|0301|MAGNESIUM|United Healthcare|GEHA|||||2.57||| 83735|EAP|0301|MAGNESIUM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.57||||2.57||| 83735|EAP|0301|MAGNESIUM|United Medicare Advantage|UHC MEDICARE GOLD MA|2.57||||2.57||| 83735|EAP|0301|MAGNESIUM|Medicare|MEDICARE PART B ONLY IP|2.57||||||| 83735|EAP|0301|MAGNESIUM|United Medicare Advantage|AARP UHC WEST COMPLETE MA|2.57||||0.60||| 83735|EAP|0301|MAGNESIUM|United Healthcare|TML GROUP BENEFITS|2.57||||||| 83735|EAP|0301|MAGNESIUM|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||2.57||| 83735|EAP|0301|MAGNESIUM|Managed Medicaid|MEDICAID AMERIGROUP|||||2.57||| 83735|EAP|0301|MAGNESIUM|Managed Medicaid|MEDICAID SUPERIOR|2.57||||2.57||| 83735|EAP|0301|MAGNESIUM|Workers Compensation|WORKERS COMPENSATION OTHER|2.57||||2.57||| 83735|EAP|0301|MAGNESIUM|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|2.57||||||| 83735|EAP|0301|MAGNESIUM|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|2.57||||||| 83735|EAP|0301|MAGNESIUM|Aenta Medicare Advantage|AETNA MEDICARE MA|2.57||||2.57||| 83735|EAP|0301|MAGNESIUM|Aetna|AETNA OTHER|2.57||||0.60||| 83735|EAP|0301|MAGNESIUM|Brinson Benefits|THE HEALTH PLAN SMITH CO|2.57||||||| 83735|EAP|0301|MAGNESIUM|Cigna|CIGNA|||||0.60||| 83735|EAP|0301|MAGNESIUM|Humana Medicare Advantage|HUMANA MA|2.57||||2.57||| 83735|EAP|0301|MAGNESIUM|Blue Cross PPO Specialty|BCBSTX PPO|2.57||||2.57||| 83735|EAP|0301|MAGNESIUM|Cigna|CIGNA|2.57||||158.50||| 83735|EAP|0301|MAGNESIUM|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.57||||158.50||| 83735|EAP|0301|MAGNESIUM 24 HR URINE|Humana Medicare Advantage|HUMANA MA|2.57||||0.60||| 83735|EAP|0301|MAGNESIUM|Blue Cross HMO Specialty|BCBSTX HMO|2.57||||2.57||| 83735|EAP|0301|MAGNESIUM|Aetna|AETNA PPO|2.57||||2.57||| 83735|EAP|0301|MAGNESIUM|Blue Cross PPO Specialty|BCBSTX OTHER|2.57||||158.50||| 83735|EAP|0301|MAGNESIUM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.57||||2.57||| 83735|EAP|0301|MAGNESIUM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.57||||2.57||| 83735|EAP|0301|MAGNESIUM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.57||||0.60||| 83789|EAP|0300|BILE ACIDS, FRACTIONATED|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||237.50||| 83789|EAP|0300|BILE ACIDS, FRACTIONATED|Blue Cross HMO Specialty|BCBSTX HMO|||||618.25||| 83789|EAP|0300|BILE ACIDS, FRACTIONATED|United Healthcare|UNITED HEALTHCARE|||||237.50||| 83789|EAP|0300|BILE ACIDS, FRACTIONATED|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||237.50||| 83789|EAP|0300|BILE ACIDS, FRACTIONATED|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||237.50||| 83789|EAP|0300|BILE ACIDS, FRACTIONATED|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||237.50||| 83789|EAP|0300|BILE ACIDS, FRACTIONATED|Managed Medicaid|MEDICAID SUPERIOR|237.50||||237.50||| 83789|EAP|0300|BILE ACIDS, FRACTIONATED|Medicaid|MEDICAID HMO|||||237.50||| 83789|EAP|0300|BILE ACIDS, FRACTIONATED|Managed Medicaid|MEDICAID AMERIGROUP|||||237.50||| 83825|EAP|0301|MERCURY QUANATATIVE|Humana Medicare Advantage|HUMANA MA|||||1.16||| 83835|EAP|0301|METANEPHRINES FRACTIONATE|Medicare|MEDICARE ACUTE|||||151.50||| 83835|EAP|0301|PLASMA METANEPHRINES|NON CONTRACTED|COMMERCIAL OTHER 1|||||145.50||| 83835|EAP|0301|PLASMA METANEPHRINES|Medicare|MEDICARE ACUTE|||||145.50||| 83835|EAP|0301|PLASMA METANEPHRINES|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||145.50||| 83835|EAP|0301|PLASMA METANEPHRINES|Managed Medicaid|MEDICAID SUPERIOR|||||145.50||| 83835|EAP|0301|PLASMA METANEPHRINES|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||145.50||| 83835|EAP|0301|PLASMA METANEPHRINES|United Medicare Advantage|UHC MEDICARE GOLD MA|||||145.50||| 83835|EAP|0301|PLASMA METANEPHRINES|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||145.50||| 83835|EAP|0307|FREE METANEPHRINES PLASMA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||151.50||| 83835|EAP|0301|PLASMA METANEPHRINES|Blue Cross PPO Specialty|BCBSTX PPO|||||145.50||| 83835|EAP|0301|PLASMA METANEPHRINES|Humana Medicare Advantage|HUMANA MA|||||145.50||| 83874|EAP|0301|MYOGLOBIN URINE|Blue Cross PPO Specialty|BCBSTX PPO|||||494.75||| 83874|EAP|0301|MYOGLOBIN SERUM|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||115.50||| 83874|EAP|0301|MYOGLOBIN SERUM|Humana Medicare Advantage|HUMANA MA|||||115.50||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|Managed Medicaid|MEDICAID AMERIGROUP|||||1,310.75||| 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|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1,310.75||||807.13||| 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|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||||303.50||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|Medicaid|MEDICAID|1,310.75||||1,310.75||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||1,310.75||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||1,310.75||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|Rusk State Hospital|RUSK STATE HOSP|1,310.75||||1,310.75||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|Medicare|MEDICARE PART B ONLY IP|1,310.75||||||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|Tricare|TRICARE EAST REGION|||||807.13||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|NON CONTRACTED|COMMERCIAL OTHER 2|||||1,310.75||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|NON CONTRACTED|COMMERCIAL OTHER 1|1,310.75||||303.50||| 83880|EAP|0300|PRO-BNP|Medicare|MEDICARE ACUTE|||||303.50||| 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|Workers Compensation|UT EMPLOYEE INJURY|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|UNITED HEALTHCARE OTHER|||||807.13||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|United Healthcare|UNITED HEALTHCARE|1,310.75||||303.50||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|United Healthcare|UNITED HEALTHCARE|||||1,310.75||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|United Healthcare|TML GROUP BENEFITS|1,310.75||||||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|United Healthcare|GEHA|||||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|UHC MEDICARE GOLD MA|1,310.75||||303.50||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||303.50||| 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|Workers Compensation|WORKERS COMPENSATION OTHER|||||1,310.75||| 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|Aetna|AETNA PPO|||||1,310.75||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,310.75||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1,310.75||||303.50||| 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|Aetna|AETNA OTHER|1,310.75||||||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|Aenta Medicare Advantage|AETNA MEDICARE MA|1,310.75||||807.13||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,310.75||||303.50||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||303.50||| 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|Humana Medicare Advantage|HUMANA MA|1,310.75||||1,310.75||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|Cigna|CIGNA|||||1,310.75||| 83880|EAP|0301|N-TERMINAL PRO-BRAIN NATR|Blue Cross PPO Specialty|BCBSTX OTHER|1,310.75||||303.50||| 83883|EAP|0300|FREE LAMBDA LIGHT CHAINS|Humana Medicare Advantage|HUMANA MA|||||115.50||| 83883|EAP|0300|FREE KAPPA LIGHT CHAINS Q|Blue Cross PPO Specialty|BCBSTX PPO|||||115.50||| 83883|EAP|0300|FREE LAMBDA LIGHT CHAINS|Blue Cross PPO Specialty|BCBSTX PPO|||||115.50||| 83883|EAP|0300|FREE KAPPA LIGHT CHAINS Q|Humana Medicare Advantage|HUMANA MA|||||115.50||| 83883|EAP|0300|FREE LAMBDA LIGHT CHAINS|United Healthcare|UNITED HEALTHCARE|||||115.50||| 83883|EAP|0300|FREE LAMBDA LIGHT CHAINS|Veterans Affairs|VETERANS ADMINISTRATION|||||115.50||| 83883|EAP|0300|FREE KAPPA LIGHT CHAINS Q|United Healthcare|UNITED HEALTHCARE|||||115.50||| 83883|EAP|0300|FREE KAPPA LIGHT CHAINS Q|Veterans Affairs|VETERANS ADMINISTRATION|||||115.50||| 83883|EAP|0300|FREE LAMBDA LIGHT CHAINS|NON CONTRACTED|COMMERCIAL OTHER 1|||||115.50||| 83883|EAP|0300||Medicare|MEDICARE ACUTE|384.75||||1.20||| 83883|EAP|0300|ALPHA 2 MACROGLOBULIN|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.92||| 83883|EAP|0300|FREE KAPPA LIGHT CHAINS Q|Medicare|MEDICARE ACUTE|384.75||||115.50||| 83883|EAP|0300|FREE KAPPA LIGHT CHAINS Q|NON CONTRACTED|COMMERCIAL OTHER 1|||||115.50||| 83883|EAP|0300|FREE LAMBDA LIGHT CHAINS|Medicare|MEDICARE ACUTE|384.75||||115.50||| 83918|EAP|0300|ORGANIC ACID SCREEN (NON|Blue Cross HMO Specialty|BCBSTX HMO|||||226.25||| 83921|EAP|0300|METHYLMALONIC ACID|Blue Cross PPO Specialty|BCBSTX PPO|||||147.25||| 83921|EAP|0300|METHYLMALONIC ACID|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||147.25||| 83921|EAP|0300|METHYLMALONIC ACID|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||147.25||| 83930|EAP|0301|OSMOLALITY SERUM|Medicare|MEDICARE ACUTE|188.75||||||| 83930|EAP|0301|OSMOLALITY SERUM|United Medicare Advantage|UHC MEDICARE GOLD MA|188.75||||||| 83930|EAP|0301|OSMOLALITY SERUM|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|188.75||||||| 83935|EAP|0301|OSMOLALITY URINE|Blue Cross HMO Specialty|BCBSTX HMO|||||0.44||| 83935|EAP|0301|OSMOLALITY URINE|Blue Cross PPO Specialty|BCBSTX PPO|||||0.44||| 83935|EAP|0301|OSMOLALITY URINE|Humana Medicare Advantage|HUMANA MA|188.75||||||| 83935|EAP|0301|OSMOLALITY URINE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||0.44||| 83935|EAP|0301|OSMOLALITY URINE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.44||| 83935|EAP|0301|OSMOLALITY URINE|United Medicare Advantage|UHC MEDICARE GOLD MA|188.75||||||| 83935|EAP|0301|OSMOLALITY URINE|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|188.75||||||| 83935|EAP|0301|OSMOLALITY URINE|Managed Medicaid|MEDICAID AMERIGROUP|188.75||||0.44||| 83935|EAP|0301|OSMOLALITY URINE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.44||| 83935|EAP|0301|OSMOLALITY URINE|Medicaid|MEDICAID|188.75||||||| 83935|EAP|0301|OSMOLALITY URINE|Medicare|MEDICARE ACUTE|188.75||||0.44||| 83935|EAP|0301|OSMOLALITY URINE|UTMB|UTMB CORRECTIONAL MANAGED CARE|188.75||||||| 83970|EAP|0301|PTH INTACT|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||3.69||| 83970|EAP|0301|PTH INTACT|Tricare|TRICARE EAST REGION|||||3.69||| 83970|EAP|0301|PTH INTACT|NON CONTRACTED|COMMERCIAL OTHER 1|||||3.69||| 83970|EAP|0301|PTH INTACT|Medicare|MEDICARE ACUTE|13.39||||3.69||| 83970|EAP|0301|PTH INTACT|Medicaid|MEDICAID TEXAS CHILDRENS|||||3.69||| 83970|EAP|0301|PTH INTACT|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||3.69||| 83970|EAP|0301|PTH INTACT|Medicaid|MEDICAID|||||3.69||| 83970|EAP|0301|PTH INTACT|Humana Medicare Advantage|HUMANA MA|13.39||||3.69||| 83970|EAP|0301|PTH INTACT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||3.69||| 83970|EAP|0301|PTH INTACT|Blue Cross PPO Specialty|BCBSTX PPO|13.39||||3.69||| 83970|EAP|0301|PTH INTACT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3.69||| 83970|EAP|0301|PTH INTACT|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||3.69||| 83970|EAP|0301|PTH INTACT|Managed Medicaid|MEDICAID AMERIGROUP|||||3.69||| 83970|EAP|0301|PTH INTACT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|13.39||||3.69||| 83970|EAP|0301|PTH INTACT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||3.69||| 83986|EAP|0300|PH BODY FLUID|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|136.75||||||| 83986|EAP|0300|PH BODY FLUID|Medicare|MEDICARE ACUTE|136.75||||||| 83986|EAP|0300|PH BODY FLUID|UTMB|UTMB CORRECTIONAL MANAGED CARE|136.75||||||| 83986|EAP|0301|PH FECES|Managed Medicaid|MEDICAID SUPERIOR|||||0.32||| 83993|EAP|0300|CALPROTECTIN, FECAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||139.25||| 83993|EAP|0300|CALPROTECTIN, FECAL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||139.25||| 83993|EAP|0300|CALPROTECTIN, FECAL|United Healthcare|TML GROUP BENEFITS|||||139.25||| 83993|EAP|0300|CALPROTECTIN, FECAL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||139.25||| 83993|EAP|0300|CALPROTECTIN, FECAL|Medicare|MEDICARE ACUTE|||||139.25||| 840|DRG||LYMPHOMA & NON-ACUTE LEUKEMIA W MCC|Medicare|MEDICARE ACUTE|93,213.50|24201.72|24201.72|24201.72|||| 84066|EAP|0300|PROSTATIC ACID PHOSPHATAS|Humana Medicare Advantage|HUMANA MA|||||86.25||| 84080|EAP|0300|ALKALINE PHOSPHATASE, BON|Managed Medicare|HEALTHSPRING MA|||||46.25||| 84080|EAP|0301|ALKALINE PHOS ISOENZYMES|Managed Medicare|HEALTHSPRING MA|||||78.25||| 84080|EAP|0301|ALKALINE PHOS ISOENZYMES|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||78.25||| 84080|EAP|0300|ALKALINE PHOSPHATASE, BON|Medicaid|MEDICAID|||||46.25||| 84080|EAP|0301|ALKALINE PHOS ISOENZYMES|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||78.25||| 84080|EAP|0301|ALKALINE PHOS ISOENZYMES|Medicare|MEDICARE ACUTE|||||78.25||| 84080|EAP|0301|ALKALINE PHOS ISOENZYMES|NON CONTRACTED|COMMERCIAL OTHER 1|||||78.25||| 84080|EAP|0300|ALKALINE PHOSPHATASE, BON|Medicare|MEDICARE ACUTE|||||46.25||| 84080|EAP|0301|ALKALINE PHOS ISOENZYMES|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||78.25||| 84080|EAP|0300|ALKALINE PHOSPHATASE, BON|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||46.25||| 84080|EAP|0300|ALKALINE PHOSPHATASE, BON|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||46.25||| 84080|EAP|0300|ALKALINE PHOSPHATASE, BON|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||46.25||| 84080|EAP|0300|ALKALINE PHOSPHATASE, BON|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||46.25||| 84080|EAP|0300|ALKALINE PHOSPHATASE, BON|Aenta Medicare Advantage|AETNA MEDICARE MA|||||46.25||| 84080|EAP|0301|ALKALINE PHOS ISOENZYMES|Aenta Medicare Advantage|AETNA MEDICARE MA|||||78.25||| 84080|EAP|0301|ALKALINE PHOS ISOENZYMES|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||78.25||| 84080|EAP|0300|ALKALINE PHOSPHATASE, BON|Cigna|CIGNA|||||46.25||| 84080|EAP|0300|ALKALINE PHOSPHATASE, BON|Humana Medicare Advantage|HUMANA MA|1.42||||46.25||| 84080|EAP|0300|ALKALINE PHOSPHATASE, BON|Blue Cross PPO Specialty|BCBSTX PPO|||||46.25||| 84080|EAP|0301|ALKALINE PHOS ISOENZYMES|Blue Cross PPO Specialty|BCBSTX PPO|||||78.25||| 84080|EAP|0301|ALKALINE PHOS ISOENZYMES|Humana Medicare Advantage|HUMANA MA|335.25||||78.25||| 84080|EAP|0301|ALKALINE PHOS ISOENZYMES|Cigna|CIGNA|||||78.25||| 84080|EAP|0300|ALKALINE PHOSPHATASE, BON|NON CONTRACTED|COMMERCIAL OTHER 1|||||46.25||| 84081|EAP|0300|PHOSPHATIDYL|Managed Medicaid|MEDICAID SUPERIOR|||||147.75||| 84100|EAP|0300|PHOSPHORUS BLOOD|Brinson Benefits|THE HEALTH PLAN SMITH CO|1.82||||||| 84100|EAP|0300|PHOSPHORUS BLOOD|Blue Cross PPO Specialty|BCBSTX PPO|1.82||||1.82||| 84100|EAP|0300|PHOSPHORUS BLOOD|Humana Medicare Advantage|HUMANA MA|1.82||||42.25||| 84100|EAP|0300|PHOSPHORUS BLOOD|Blue Cross PPO Specialty|BCBSTX OTHER|1.82||||42.25||| 84100|EAP|0300|PHOSPHORUS BLOOD|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.82||||1.82||| 84100|EAP|0300|PHOSPHORUS BLOOD|Cigna|CIGNA|1.82||||||| 84100|EAP|0300|PHOSPHORUS BLOOD|Cigna|CIGNA|||||1.82||| 84100|EAP|0300|PHOSPHORUS BLOOD|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.82||||112.13||| 84100|EAP|0300|PHOSPHORUS BLOOD|Aenta Medicare Advantage|AETNA MEDICARE MA|1.82||||42.25||| 84100|EAP|0300|PHOSPHORUS BLOOD|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.82||||||| 84100|EAP|0300|PHOSPHORUS BLOOD|Blue Cross HMO Specialty|BCBSTX HMO|1.82||||42.25||| 84100|EAP|0300|PHOSPHORUS BLOOD|Aetna|AETNA PPO|1.82||||1.82||| 84100|EAP|0300|PHOSPHORUS BLOOD|Aetna|AETNA OTHER|1.82||||42.25||| 84100|EAP|0300|PHOSPHORUS BLOOD|Workers Compensation|WORKERS COMPENSATION OTHER|1.82||||||| 84100|EAP|0300|PHOSPHORUS BLOOD|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.82||||1.82||| 84100|EAP|0300|PHOSPHORUS BLOOD|United Medicare Advantage|AARP UHC WEST COMPLETE MA|1.82||||42.25||| 84100|EAP|0300|PHOSPHORUS BLOOD|Workers Compensation|UT EMPLOYEE INJURY|1.82||||||| 84100|EAP|0300|PHOSPHORUS BLOOD|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.82||||42.25||| 84100|EAP|0300|PHOSPHORUS BLOOD|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|1.82||||||| 84100|EAP|0300|PHOSPHORUS BLOOD|Veterans Affairs|VETERANS ADMINISTRATION|1.82||||1.82||| 84100|EAP|0300|PHOSPHORUS BLOOD|United Healthcare|UMR UNITED MEDICAL RESOURCES|1.82||||||| 84100|EAP|0300|PHOSPHORUS BLOOD|United Healthcare|UNITED HEALTHCARE|1.82||||||| 84100|EAP|0300|PHOSPHORUS BLOOD|United Healthcare|TML GROUP BENEFITS|1.82||||||| 84100|EAP|0300|PHOSPHORUS BLOOD|Tricare|TRICARE EAST REGION|||||42.25||| 84100|EAP|0300|PHOSPHORUS BLOOD|NON CONTRACTED|COMMERCIAL OTHER 2|||||1.82||| 84100|EAP|0300|PHOSPHORUS BLOOD|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|1.82||||||| 84100|EAP|0300|PHOSPHORUS BLOOD|NON CONTRACTED|COMMERCIAL OTHER 1|1.82||||42.25||| 84100|EAP|0300|PHOSPHORUS BLOOD|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.82||||||| 84100|EAP|0300|PHOSPHORUS BLOOD|United Medicare Advantage|UHC MEDICARE GOLD MA|1.82||||42.25||| 84100|EAP|0300|PHOSPHORUS BLOOD|Medicare|MEDICARE ACUTE|1.82||||42.25||| 84100|EAP|0300|PHOSPHORUS BLOOD|Medicare|MEDICARE PART B ONLY IP|1.82||||||| 84100|EAP|0300|PHOSPHORUS BLOOD|Rusk State Hospital|RUSK STATE HOSP|1.82||||||| 84100|EAP|0300|PHOSPHORUS BLOOD|Managed Medicaid|MEDICAID SUPERIOR|1.82||||42.25||| 84100|EAP|0300|PHOSPHORUS BLOOD|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.82||||42.25||| 84100|EAP|0300|PHOSPHORUS BLOOD|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.82||||42.25||| 84100|EAP|0300|PHOSPHORUS BLOOD|Managed Medicaid|MEDICAID AMERIGROUP|||||42.25||| 84100|EAP|0300|PHOSPHORUS BLOOD|Medicaid|MEDICAID TEXAS CHILDRENS|||||42.25||| 84100|EAP|0300|PHOSPHORUS BLOOD|Medicaid|MEDICAID|1.82||||112.13||| 84100|EAP|0300|PHOSPHORUS BLOOD|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.82||||||| 84100|EAP|0300|PHOSPHORUS BLOOD|Managed Medicare|HEALTHSPRING MA|1.82||||42.25||| 84100|EAP|0300|PHOSPHORUS BLOOD|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||1.82||| 84100|EAP|0300|PHOSPHORUS BLOOD|Medicaid|COUNTY INDIGENT HEALTH OTHER|1.82||||||| 84112|EAP|0300|AMNISURE|Managed Medicaid|MEDICAID SUPERIOR|3.10||||3.10||| 84112|EAP|0300|AMNISURE|Managed Medicaid|MEDICAID AMERIGROUP|3.10||||3.10||| 84112|EAP|0300|AMNISURE|Medicaid|MEDICAID HMO|||||3.10||| 84112|EAP|0300|AMNISURE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||3.10||| 84112|EAP|0300|AMNISURE|Medicaid|MEDICAID|3.10||||3.10||| 84112|EAP|0300|AMNISURE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||3.10||| 84112|EAP|0300|AMNISURE|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||3.10||| 84112|EAP|0300|AMNISURE|NON CONTRACTED|COMMERCIAL OTHER 1|3.10||||3.10||| 84112|EAP|0300|AMNISURE|NON CONTRACTED|COMMERCIAL OTHER 2|||||3.10||| 84112|EAP|0300|AMNISURE|United Healthcare|UNITED HEALTHCARE OTHER|||||3.10||| 84112|EAP|0300|AMNISURE|Blue Cross HMO Specialty|BCBSTX HMO|3.10||||3.10||| 84112|EAP|0300|AMNISURE|Blue Cross PPO Specialty|BCBSTX PPO|3.10||||3.10||| 84112|EAP|0300|AMNISURE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3.10||||3.10||| 84112|EAP|0300|AMNISURE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.10||||3.10||| 84112|EAP|0300|AMNISURE|United Healthcare|UNITED HEALTHCARE|3.10||||3.10||| 84132|EAP|0300|POTASSIUM BLOOD|Blue Cross PPO Specialty|BCBSTX PPO|175.75||||175.75||| 84132|EAP|0300|POTASSIUM BLOOD|Blue Cross PPO Specialty|BCBSTX OTHER|175.75||||||| 84132|EAP|0300|POTASSIUM BLOOD|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.41||| 84132|EAP|0300|POTASSIUM BLOOD|Aenta Medicare Advantage|AETNA MEDICARE MA|175.75||||175.75||| 84132|EAP|0300|POTASSIUM BLOOD|Blue Cross HMO Specialty|BCBSTX HMO|||||108.38||| 84132|EAP|0300|POTASSIUM BLOOD|Veterans Affairs|VETERANS ADMINISTRATION|175.75||||||| 84132|EAP|0300|POTASSIUM BLOOD|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|175.75||||||| 84132|EAP|0300|POTASSIUM BLOOD|United Medicare Advantage|UHC MEDICARE GOLD MA|175.75||||175.75||| 84132|EAP|0300|POTASSIUM BLOOD|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|175.75||||175.75||| 84132|EAP|0300|POTASSIUM BLOOD|United Healthcare|UMR UNITED MEDICAL RESOURCES|175.75||||||| 84132|EAP|0300|POTASSIUM BLOOD|United Healthcare|UNITED HEALTHCARE OTHER|175.75||||||| 84132|EAP|0300|POTASSIUM BLOOD|Workers Compensation|WORKERS COMPENSATION OTHER|175.75||||||| 84132|EAP|0300|POTASSIUM BLOOD|NON CONTRACTED|COMMERCIAL OTHER 1|175.75||||||| 84132|EAP|0300|POTASSIUM BLOOD|Humana Medicare Advantage|HUMANA MA|175.75||||175.75||| 84132|EAP|0300|POTASSIUM BLOOD|Medicare|MEDICARE ACUTE|175.75||||0.41||| 84132|EAP|0300|POTASSIUM BLOOD|Rusk State Hospital|RUSK STATE HOSP|175.75||||175.75||| 84132|EAP|0300|POTASSIUM BLOOD|UTMB|UTMB CORRECTIONAL MANAGED CARE|175.75||||175.75||| 84132|EAP|0300|POTASSIUM BLOOD|Managed Medicaid|MEDICAID UNITED HEALTHCARE|175.75||||175.75||| 84132|EAP|0300|POTASSIUM BLOOD|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|175.75||||0.41||| 84132|EAP|0300|POTASSIUM BLOOD|Medicaid|MEDICAID|175.75||||0.41||| 84132|EAP|0300|POTASSIUM BLOOD|Managed Medicaid|MEDICAID SUPERIOR|175.75||||108.38||| 84132|EAP|0300|POTASSIUM BLOOD|Managed Medicaid|MEDICAID AMERIGROUP|||||0.41||| 84132|EAP|0300|POTASSIUM BLOOD|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|175.75||||||| 84132|EAP|0300|POTASSIUM BLOOD|Managed Medicare|HEALTHSPRING MA|175.75||||||| 84133|EAP|0300|24 HOUR URINE POTASSIUM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||38.50||| 84133|EAP|0300|POTASSIUM URINE,RANDOM|Medicaid|MEDICAID|164.50||||||| 84133|EAP|0300|24 HOUR URINE POTASSIUM|Blue Cross HMO Specialty|BCBSTX HMO|||||38.50||| 84133|EAP|0300|24 HOUR URINE POTASSIUM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||38.50||| 84133|EAP|0300|POTASSIUM URINE,RANDOM|Humana Medicare Advantage|HUMANA MA|||||38.50||| 84133|EAP|0300|24 HOUR URINE POTASSIUM|Blue Cross PPO Specialty|BCBSTX PPO|||||38.50||| 84133|EAP|0300|24 HOUR URINE POTASSIUM|Medicare|MEDICARE ACUTE|||||38.50||| 84133|EAP|0300|24 HOUR URINE POTASSIUM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||38.50||| 84134|EAP|0300|PREALBUMIN|Cigna|CIGNA|||||75.50||| 84134|EAP|0300|PREALBUMIN|Humana Medicare Advantage|HUMANA MA|323.25||||75.50||| 84134|EAP|0300|PREALBUMIN|Blue Cross HMO Specialty|BCBSTX HMO|||||75.50||| 84134|EAP|0300|PREALBUMIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|323.25||||75.50||| 84134|EAP|0300|PREALBUMIN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||75.50||| 84134|EAP|0300|PREALBUMIN|United Medicare Advantage|UHC MEDICARE GOLD MA|||||75.50||| 84134|EAP|0300|PREALBUMIN|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||75.50||| 84134|EAP|0300|PREALBUMIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||75.50||| 84134|EAP|0300|PREALBUMIN|Brinson Benefits|THE HEALTH PLAN SMITH CO|323.25||||||| 84134|EAP|0300|PREALBUMIN|NON CONTRACTED|COMMERCIAL OTHER 1|||||75.50||| 84134|EAP|0300|PREALBUMIN|Medicare|MEDICARE ACUTE|323.25||||75.50||| 84134|EAP|0300|PREALBUMIN|Rusk State Hospital|RUSK STATE HOSP|323.25||||||| 84134|EAP|0300|PREALBUMIN|Tricare|TRICARE EAST REGION|||||75.50||| 84134|EAP|0300|PREALBUMIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||75.50||| 84134|EAP|0300|PREALBUMIN|Managed Medicaid|MEDICAID SUPERIOR|||||75.50||| 84134|EAP|0300|PREALBUMIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|323.25||||75.50||| 84134|EAP|0300|PREALBUMIN|Managed Medicaid|MEDICAID AMERIGROUP|||||75.50||| 84134|EAP|0300|PREALBUMIN|Managed Medicare|HEALTHSPRING MA|323.25||||75.50||| 84134|EAP|0300|PREALBUMIN|Medicaid|MEDICAID TEXAS CHILDRENS|||||75.50||| 84140|EAP|0300|PREGNENOLONE|Blue Cross PPO Specialty|BCBSTX PPO|||||184.75||| 84144|EAP|0300|PROGESTERONE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||186.50||| 84144|EAP|0300|PROGESTERONE|Managed Medicaid|MEDICAID SUPERIOR|||||186.50||| 84144|EAP|0300|PROGESTERONE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||186.50||| 84144|EAP|0300|PROGESTERONE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||186.50||| 84144|EAP|0300|PROGESTERONE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||186.50||| 84144|EAP|0300|PROGESTERONE|Blue Cross HMO Specialty|BCBSTX HMO|||||186.50||| 84144|EAP|0300|PROGESTERONE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||186.50||| 84144|EAP|0300|PROGESTERONE|Blue Cross PPO Specialty|BCBSTX PPO|||||186.50||| 84144|EAP|0300|PROGESTERONE|Blue Cross PPO Specialty|BCBSTX OTHER|||||186.50||| 84145|EAP|0300|PROCALCITONIN|Humana Medicare Advantage|HUMANA MA|921.50||||||| 84145|EAP|0300|PROCALCITONIN|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||921.50||| 84145|EAP|0300|PROCALCITONIN|Aenta Medicare Advantage|AETNA MEDICARE MA|921.50||||||| 84145|EAP|0300|PROCALCITONIN|Blue Cross HMO Specialty|BCBSTX HMO|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|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|921.50||||||| 84145|EAP|0300|PROCALCITONIN|Veterans Affairs|VETERANS ADMINISTRATION|921.50||||||| 84145|EAP|0300|PROCALCITONIN|Workers Compensation|WORKERS COMPENSATION OTHER|921.50||||||| 84145|EAP|0300|PROCALCITONIN|NON CONTRACTED|COMMERCIAL OTHER 1|921.50||||||| 84145|EAP|0300|PROCALCITONIN|Managed Medicaid|MEDICAID SUPERIOR|921.50||||921.50||| 84145|EAP|0300|PROCALCITONIN|Medicaid|MEDICAID|921.50||||||| 84145|EAP|0300|PROCALCITONIN|Managed Medicare|HEALTHSPRING MA|921.50||||||| 84145|EAP|0300|PROCALCITONIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|921.50||||||| 84145|EAP|0300|PROCALCITONIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|921.50||||||| 84145|EAP|0300|PROCALCITONIN|UTMB|UTMB CORRECTIONAL MANAGED CARE|921.50||||||| 84145|EAP|0300|PROCALCITONIN|Medicare|MEDICARE ACUTE|921.50||||921.50||| 84145|EAP|0300|PROCALCITONIN|Blue Cross PPO Specialty|BCBSTX PPO|921.50||||||| 84145|EAP|0300|PROCALCITONIN|Rusk State Hospital|RUSK STATE HOSP|921.50||||||| 84146|EAP|0300|PROLACTIN|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||173.25||| 84146|EAP|0300|PROLACTIN|Managed Medicaid|MEDICAID AMERIGROUP|||||173.25||| 84146|EAP|0300|PROLACTIN|Managed Medicaid|MEDICAID SUPERIOR|||||173.25||| 84146|EAP|0300|PROLACTIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||173.25||| 84146|EAP|0300|PROLACTIN|NON CONTRACTED|COMMERCIAL OTHER 1|||||173.25||| 84146|EAP|0300|PROLACTIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||173.25||| 84146|EAP|0300|PROLACTIN|Medicare|MEDICARE ACUTE|||||173.25||| 84146|EAP|0300|PROLACTIN|United Healthcare|UNITED HEALTHCARE|||||173.25||| 84146|EAP|0300|PROLACTIN|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||173.25||| 84146|EAP|0300|PROLACTIN|Blue Cross HMO Specialty|BCBSTX HMO|||||173.25||| 84146|EAP|0300|PROLACTIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||173.25||| 84146|EAP|0300|PROLACTIN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||173.25||| 84146|EAP|0300|PROLACTIN|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||173.25||| 84146|EAP|0300|PROLACTIN|Humana Medicare Advantage|HUMANA MA|||||173.25||| 84146|EAP|0300|PROLACTIN|Blue Cross PPO Specialty|BCBSTX PPO|742.75||||173.25||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Humana Medicare Advantage|HUMANA MA|||||164.25||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Blue Cross PPO Specialty|BCBSTX PPO|||||164.25||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Cigna|CIGNA|||||164.25||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Blue Cross HMO Specialty|BCBSTX HMO|||||164.25||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||164.25||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||164.25||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||164.25||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Aetna|AETNA PPO|||||164.25||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||164.25||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|United Medicare Advantage|UHC MEDICARE GOLD MA|704.50||||164.25||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|704.50||||164.25||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||164.25||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|United Healthcare|UNITED HEALTHCARE OTHER|||||164.25||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||164.25||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|United Healthcare|AARP|||||164.25||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|United Healthcare|UNITED HEALTHCARE|||||164.25||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|United Healthcare|TML GROUP BENEFITS|||||164.25||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Blue Cross PPO Specialty|BCBSTX OTHER|||||164.25||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Aenta Medicare Advantage|AETNA MEDICARE MA|||||164.25||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|NON CONTRACTED|COMMERCIAL OTHER 1|||||164.25||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|PHCS|HUMANA INSURANCE|||||164.25||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Medicare|MEDICARE PART B ONLY IP|||||164.25||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Medicare|MEDICARE ACUTE|704.50||||164.25||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Tricare|TRICARE EAST REGION|||||164.25||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||164.25||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Managed Medicaid|MEDICAID SUPERIOR|||||164.25||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||164.25||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||164.25||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Managed Medicare|HEALTHSPRING MA|||||164.25||| 84153|EAP|0300|PROSTATE SPECIFIC ANTIGEN|Medicaid|MEDICAID|||||164.25||| 84154|EAP|0300|PSA FREE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||164.25||| 84154|EAP|0300|PSA FREE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||164.25||| 84154|EAP|0300|PSA FREE|Blue Cross HMO Specialty|BCBSTX HMO|||||164.25||| 84155|EAP|0300|VOLUME MEASUREMENT URINE|United Healthcare|UNITED HEALTHCARE|||||26.75||| 84155|EAP|0300|VOLUME MEASUREMENT URINE|Veterans Affairs|VETERANS ADMINISTRATION|||||26.75||| 84155|EAP|0302|IMMUNOFIXATION ELECTROPHO|United Medicare Advantage|UHC MEDICARE GOLD MA|8.56||||199.75||| 84155|EAP|0300|VOLUME MEASUREMENT URINE|United Healthcare|UNITED HEALTHCARE OTHER|||||26.75||| 84155|EAP|0302|IMMUNOFIXATION ELECTROPHO|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||199.75||| 84155|EAP|0300|VOLUME MEASUREMENT URINE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||26.75||| 84155|EAP|0302|IMMUNOFIXATION ELECTROPHO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||199.75||| 84155|EAP|0300|VOLUME MEASUREMENT URINE|Blue Cross PPO Specialty|BCBSTX PPO|114.75||||26.75||| 84155|EAP|0300|VOLUME MEASUREMENT URINE|Blue Cross PPO Specialty|BCBSTX OTHER|||||26.75||| 84155|EAP|0301|PROTEIN, TOTAL SERUM|Brinson Benefits|THE HEALTH PLAN SMITH CO|140.50||||||| 84155|EAP|0302|IMMUNOFIXATION ELECTROPHO|Humana Medicare Advantage|HUMANA MA|||||199.75||| 84155|EAP|0302|IMMUNOFIXATION ELECTROPHO|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|8.56||||||| 84155|EAP|0302|IMMUNOFIXATION ELECTROPHO|Cigna|CIGNA|||||199.75||| 84155|EAP|0300|VOLUME MEASUREMENT URINE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|114.75||||||| 84155|EAP|0300|VOLUME MEASUREMENT URINE|Humana Medicare Advantage|HUMANA MA|||||26.75||| 84155|EAP|0302|IMMUNOFIXATION ELECTROPHO|Blue Cross PPO Specialty|BCBSTX PPO|||||199.75||| 84155|EAP|0302|IMMUNOFIXATION ELECTROPHO|Blue Cross HMO Specialty|BCBSTX HMO|||||199.75||| 84155|EAP|0300|VOLUME MEASUREMENT URINE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||26.75||| 84155|EAP|0302|IMMUNOFIXATION ELECTROPHO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||199.75||| 84155|EAP|0302|IMMUNOFIXATION ELECTROPHO|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||199.75||| 84155|EAP|0302|IMMUNOFIXATION ELECTROPHO|Medicare|MEDICARE ACUTE|8.56||||199.75||| 84155|EAP|0302|IMMUNOFIXATION ELECTROPHO|Tricare|TRICARE EAST REGION|||||199.75||| 84155|EAP|0300|VOLUME MEASUREMENT URINE|NON CONTRACTED|COMMERCIAL OTHER 1|||||26.75||| 84155|EAP|0300|VOLUME MEASUREMENT URINE|Medicare|MEDICARE ACUTE|114.75||||26.75||| 84155|EAP|0300|VOLUME MEASUREMENT URINE|Blue Cross HMO Specialty|BCBSTX HMO|||||26.75||| 84155|EAP|0302|IMMUNOFIXATION ELECTROPHO|NON CONTRACTED|COMMERCIAL OTHER 1|||||199.75||| 84155|EAP|0302|IMMUNOFIXATION ELECTROPHO|Managed Medicare|BCBS MEDICARE PPO MA|||||199.75||| 84155|EAP|0300|VOLUME MEASUREMENT URINE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||26.75||| 84155|EAP|0300|VOLUME MEASUREMENT URINE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||26.75||| 84155|EAP|0300|VOLUME MEASUREMENT URINE|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||26.75||| 84155|EAP|0300|VOLUME MEASUREMENT URINE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||26.75||| 84155|EAP|0301|PROTEIN, TOTAL SERUM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|140.50||||||| 84155|EAP|0302|IMMUNOFIXATION ELECTROPHO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8.56||||199.75||| 84155|EAP|0302|IMMUNOFIXATION ELECTROPHO|Medicaid|MEDICAID|||||199.75||| 84155|EAP|0300|VOLUME MEASUREMENT URINE|Medicaid|MEDICAID|114.75||||26.75||| 84155|EAP|0300|VOLUME MEASUREMENT URINE|Managed Medicaid|MEDICAID AMERIGROUP|114.75||||70.75||| 84155|EAP|0302|IMMUNOFIXATION ELECTROPHO|Managed Medicaid|MEDICAID AMERIGROUP|||||199.75||| 84155|EAP|0302|IMMUNOFIXATION ELECTROPHO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||199.75||| 84155|EAP|0300|VOLUME MEASUREMENT URINE|Managed Medicaid|MEDICAID SUPERIOR|114.75||||114.75||| 84155|EAP|0300|VOLUME MEASUREMENT URINE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||26.75||| 84156|EAP|0300|PROTEIN TOTAL EX BY REFRA|Medicaid|MEDICAID|140.50||||32.75||| 84156|EAP|0300|PROTEIN TOTAL EX BY REFRA|Managed Medicaid|MEDICAID SUPERIOR|140.50||||140.50||| 84156|EAP|0300|PROTEIN TOTAL EX BY REFRA|Managed Medicare|BCBS MEDICARE PPO MA|||||32.75||| 84156|EAP|0300|PROTEIN TOTAL EX BY REFRA|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||32.75||| 84156|EAP|0300|PROTEIN TOTAL EX BY REFRA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||32.75||| 84156|EAP|0300|PROTEIN TOTAL EX BY REFRA|NON CONTRACTED|COMMERCIAL OTHER 1|||||32.75||| 84156|EAP|0300|PROTEIN TOTAL EX BY REFRA|Medicare|MEDICARE ACUTE|140.50||||32.75||| 84156|EAP|0300|PROTEIN TOTAL EX BY REFRA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||32.75||| 84156|EAP|0300|PROTEIN TOTAL EX BY REFRA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||32.75||| 84156|EAP|0300|PROTEIN TOTAL EX BY REFRA|Managed Medicaid|MEDICAID AMERIGROUP|140.50||||86.63||| 84156|EAP|0300|PROTEIN TOTAL EX BY REFRA|Blue Cross HMO Specialty|BCBSTX HMO|||||32.75||| 84156|EAP|0300|PROTEIN TOTAL EX BY REFRA|Blue Cross PPO Specialty|BCBSTX PPO|140.50||||32.75||| 84156|EAP|0300|PROTEIN TOTAL EX BY REFRA|Humana Medicare Advantage|HUMANA MA|||||32.75||| 84156|EAP|0300|PROTEIN TOTAL EX BY REFRA|Blue Cross PPO Specialty|BCBSTX OTHER|||||32.75||| 84156|EAP|0300|PROTEIN TOTAL EX BY REFRA|United Healthcare|UNITED HEALTHCARE OTHER|||||32.75||| 84156|EAP|0300|PROTEIN TOTAL EX BY REFRA|United Medicare Advantage|UHC MEDICARE GOLD MA|||||32.75||| 84156|EAP|0300|PROTEIN TOTAL EX BY REFRA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||32.75||| 84156|EAP|0300|PROTEIN TOTAL EX BY REFRA|United Healthcare|UNITED HEALTHCARE|||||32.75||| 84156|EAP|0300|PROTEIN TOTAL EX BY REFRA|Veterans Affairs|VETERANS ADMINISTRATION|||||32.75||| 84156|EAP|0300|PROTEIN TOTAL EX BY REFRA|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|140.50||||||| 84157|EAP|0300|PROTEIN TOTAL,BODY FLUID|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|140.50||||||| 84157|EAP|0300|PROTEIN, CSF|Blue Cross PPO Specialty|BCBSTX PPO|140.50||||||| 84157|EAP|0300|PROTEIN TOTAL,BODY FLUID|Humana Medicare Advantage|HUMANA MA|140.50||||||| 84157|EAP|0300|PROTEIN TOTAL,BODY FLUID|Blue Cross PPO Specialty|BCBSTX OTHER|140.50||||||| 84157|EAP|0300|PROTEIN, CSF|Blue Cross HMO Specialty|BCBSTX HMO|140.50||||||| 84157|EAP|0300|PROTEIN TOTAL,BODY FLUID|Medicare|MEDICARE ACUTE|140.50||||||| 84157|EAP|0300|PROTEIN, CSF|Managed Medicaid|MEDICAID AMERIGROUP|140.50||||||| 84157|EAP|0300|PROTEIN, CSF|Managed Medicaid|MEDICAID UNITED HEALTHCARE|140.50||||140.50||| 84157|EAP|0300|PROTEIN TOTAL,BODY FLUID|Managed Medicaid|MEDICAID SUPERIOR|140.50||||140.50||| 84157|EAP|0300|PROTEIN, CSF|Medicaid|MEDICAID|140.50||||140.50||| 84157|EAP|0300|PROTEIN TOTAL,BODY FLUID|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|140.50||||||| 84165|EAP|0300|PROTEIN ELECTROPHORESIS S|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|411.50||||0.96||| 84165|EAP|0300|PROTEIN ELECTROPHORESIS S|Medicaid|MEDICAID|||||0.96||| 84165|EAP|0300|PROTEIN ELECTROPHORESIS S|Managed Medicare|BCBS MEDICARE PPO MA|||||0.96||| 84165|EAP|0300|PROTEIN ELECTROPHORESIS S|Managed Medicaid|MEDICAID AMERIGROUP|||||0.96||| 84165|EAP|0300|PROTEIN ELECTROPHORESIS S|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.96||| 84165|EAP|0300|PROTEIN ELECTROPHORESIS S|Tricare|TRICARE EAST REGION|||||0.96||| 84165|EAP|0300|PROTEIN ELECTROPHORESIS S|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.96||| 84165|EAP|0300|PROTEIN ELECTROPHORESIS S|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.96||| 84165|EAP|0300|PROTEIN ELECTROPHORESIS S|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.96||| 84165|EAP|0300|PROTEIN ELECTROPHORESIS S|Blue Cross HMO Specialty|BCBSTX HMO|||||0.96||| 84165|EAP|0300|PROTEIN ELECTROPHORESIS S|Cigna|CIGNA|||||0.96||| 84165|EAP|0300|PROTEIN ELECTROPHORESIS S|Medicare|MEDICARE ACUTE|411.50||||0.96||| 84165|EAP|0300|PROTEIN ELECTROPHORESIS S|Humana Medicare Advantage|HUMANA MA|||||0.96||| 84165|EAP|0300|PROTEIN ELECTROPHORESIS S|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|411.50||||||| 84165|EAP|0300|PROTEIN ELECTROPHORESIS S|Blue Cross PPO Specialty|BCBSTX PPO|||||0.96||| 84165|EAP|0300|PROTEIN ELECTROPHORESIS S|United Medicare Advantage|UHC MEDICARE GOLD MA|411.50||||0.96||| 84165|EAP|0300|PROTEIN ELECTROPHORESIS S|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||0.96||| 84165|EAP|0300|PROTEIN ELECTROPHORESIS S|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.96||| 84166|EAP|0301|PROTEIN ELECTRO/URINE/CSF|United Healthcare|UNITED HEALTHCARE|||||1.47||| 84166|EAP|0301|PROTEIN ELECTRO/URINE/CSF|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.47||| 84166|EAP|0301|PROTEIN ELECTRO/URINE/CSF|Blue Cross PPO Specialty|BCBSTX PPO|||||1.47||| 84166|EAP|0301|PROTEIN ELECTRO/URINE/CSF|Humana Medicare Advantage|HUMANA MA|||||1.47||| 84166|EAP|0301|PROTEIN ELECTRO/URINE/CSF|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.47||| 84166|EAP|0301|PROTEIN ELECTRO/URINE/CSF|Blue Cross HMO Specialty|BCBSTX HMO|||||1.47||| 84166|EAP|0301|PROTEIN ELECTRO/URINE/CSF|Medicare|MEDICARE ACUTE|683.25||||1.47||| 84166|EAP|0301|PROTEIN ELECTRO/URINE/CSF|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1.47||| 84166|EAP|0301|PROTEIN ELECTRO/URINE/CSF|Managed Medicare|BCBS MEDICARE PPO MA|||||1.47||| 84166|EAP|0301|PROTEIN ELECTRO/URINE/CSF|Medicaid|MEDICAID|||||1.47||| 84182|EAP|0300|COLLAPSIN RESPONSE MEDIAT|Humana Medicare Advantage|HUMANA MA|||||260.50||| 84207|EAP|0300|VITAMIN B-6 (PYRIDOXINE)|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||2.51||| 84207|EAP|0300|VITAMIN B-6 (PYRIDOXINE)|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.51||| 84244|EAP|0300|RENIN|United Medicare Advantage|UHC MEDICARE GOLD MA|||||196.50||| 84244|EAP|0300|RENIN|Blue Cross PPO Specialty|BCBSTX PPO|8.43||||196.50||| 84244|EAP|0300|RENIN|Humana Medicare Advantage|HUMANA MA|||||196.50||| 84244|EAP|0300|RENIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||196.50||| 84244|EAP|0300|RENIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||196.50||| 84244|EAP|0300|RENIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||196.50||| 84244|EAP|0300|RENIN|Medicare|MEDICARE ACUTE|||||196.50||| 84244|EAP|0300|RENIN|NON CONTRACTED|COMMERCIAL OTHER 1|||||196.50||| 84244|EAP|0300|RENIN|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||196.50||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Managed Medicaid|MEDICAID SUPERIOR|||||194.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Managed Medicaid|MEDICAID AMERIGROUP|||||194.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Managed Medicare|HEALTHSPRING MA|||||194.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||194.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||194.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|NON CONTRACTED|COMMERCIAL OTHER 1|||||194.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Medicare|MEDICARE ACUTE|||||194.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||194.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Aenta Medicare Advantage|AETNA MEDICARE MA|||||194.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Aetna|AETNA PPO|||||194.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||194.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Blue Cross PPO Specialty|BCBSTX PPO|||||194.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||194.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Blue Cross PPO Specialty|BCBSTX OTHER|||||194.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||194.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Humana Medicare Advantage|HUMANA MA|||||194.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||194.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Tricare|TRICARE EAST REGION|||||194.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Cigna|CIGNA|||||194.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Blue Cross HMO Specialty|BCBSTX HMO|||||194.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|United Medicare Advantage|UHC MEDICARE GOLD MA|||||194.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|United Healthcare|UNITED HEALTHCARE|||||194.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|United Healthcare|UNITED HEALTHCARE OTHER|||||194.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||194.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||194.25||| 84270|EAP|0300|SEX HORMONE BINDING GLOBU|United Healthcare|TML GROUP BENEFITS|||||194.25||| 84295|EAP|0300|SODIUM SERUM|Medicare|MEDICARE ACUTE|||||0.43||| 84295|EAP|0300|SODIUM SERUM|Medicaid|MEDICAID|||||0.43||| 84300|EAP|0300|SODIUM URINE|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|186.25||||||| 84300|EAP|0300|SODIUM 24HR URINE|Blue Cross PPO Specialty|BCBSTX PPO|||||43.50||| 84300|EAP|0300|SODIUM 24HR URINE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||43.50||| 84300|EAP|0300|SODIUM URINE|Humana Medicare Advantage|HUMANA MA|186.25||||43.50||| 84300|EAP|0300|SODIUM 24HR URINE|Humana Medicare Advantage|HUMANA MA|186.25||||43.50||| 84300|EAP|0300|SODIUM 24HR URINE|Blue Cross HMO Specialty|BCBSTX HMO|||||43.50||| 84300|EAP|0300|SODIUM URINE|United Medicare Advantage|UHC MEDICARE GOLD MA|186.25||||||| 84300|EAP|0300|SODIUM URINE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||43.50||| 84300|EAP|0300|SODIUM 24HR URINE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||43.50||| 84300|EAP|0300|SODIUM URINE|Aenta Medicare Advantage|AETNA MEDICARE MA|186.25||||||| 84300|EAP|0300|SODIUM 24HR URINE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||43.50||| 84300|EAP|0300|SODIUM URINE|Medicaid|MEDICAID|186.25||||||| 84300|EAP|0300|SODIUM URINE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||43.50||| 84300|EAP|0300|SODIUM 24HR URINE|Medicare|MEDICARE ACUTE|186.25||||43.50||| 84300|EAP|0300|SODIUM URINE|UTMB|UTMB CORRECTIONAL MANAGED CARE|186.25||||||| 84305|EAP|0300|SOMATOMEDIN C|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1.90||| 84311|EAP|0300|CHOLESTEROL,BODY FLUID|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|94.75||||||| 84376|EAP|0300|REDUCING SUBSTANCE STOOL|Managed Medicaid|MEDICAID SUPERIOR|||||0.87||| 84403|EAP|0300|TESTOSTERONE TOTAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||230.75||| 84403|EAP|0300|TESTOSTERONE TOTAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||230.75||| 84403|EAP|0300|TESTOSTERONE TOTAL|Aenta Medicare Advantage|AETNA MEDICARE MA|||||230.75||| 84403|EAP|0300|TESTOSTERONE TOTAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||230.75||| 84403|EAP|0300|TESTOSTERONE TOTAL|Aetna|AETNA PPO|||||230.75||| 84403|EAP|0300|TESTOSTERONE TOTAL|Blue Cross HMO Specialty|BCBSTX HMO|||||230.75||| 84403|EAP|0300|TESTOSTERONE TOTAL|Blue Cross PPO Specialty|BCBSTX PPO|||||230.75||| 84403|EAP|0300|TESTOSTERONE TOTAL|Blue Cross PPO Specialty|BCBSTX OTHER|||||230.75||| 84403|EAP|0300|TESTOSTERONE TOTAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||230.75||| 84403|EAP|0300|TESTOSTERONE TOTAL|Cigna|CIGNA|||||230.75||| 84403|EAP|0300|TESTOSTERONE TOTAL|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||230.75||| 84403|EAP|0300|TESTOSTERONE TOTAL|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||230.75||| 84403|EAP|0300|TESTOSTERONE TOTAL|United Healthcare|UNITED HEALTHCARE|||||230.75||| 84403|EAP|0300|TESTOSTERONE TOTAL|United Healthcare|UNITED HEALTHCARE OTHER|||||230.75||| 84403|EAP|0300|TESTOSTERONE TOTAL|United Healthcare|TML GROUP BENEFITS|||||230.75||| 84403|EAP|0300|TESTOSTERONE TOTAL|Tricare|TRICARE EAST REGION|||||230.75||| 84403|EAP|0300|TESTOSTERONE TOTAL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||230.75||| 84403|EAP|0300|TESTOSTERONE TOTAL|NON CONTRACTED|COMMERCIAL OTHER 1|||||230.75||| 84403|EAP|0300|TESTOSTERONE TOTAL|Medicare|MEDICARE ACUTE|||||230.75||| 84403|EAP|0300|TESTOSTERONE TOTAL|Managed Medicaid|MEDICAID SUPERIOR|||||230.75||| 84403|EAP|0300|TESTOSTERONE TOTAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||230.75||| 84403|EAP|0300|TESTOSTERONE TOTAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||230.75||| 84403|EAP|0300|TESTOSTERONE TOTAL|Humana Medicare Advantage|HUMANA MA|||||230.75||| 84403|EAP|0300|TESTOSTERONE TOTAL|Managed Medicaid|MEDICAID AMERIGROUP|||||230.75||| 84403|EAP|0300|TESTOSTERONE TOTAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||230.75||| 84403|EAP|0300|TESTOSTERONE TOTAL|Managed Medicare|HEALTHSPRING MA|||||230.75||| 84425|EAP|0300|THIAMINE (B1)|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||60.75||| 84425|EAP|0300|THIAMINE (B1)|Blue Cross HMO Specialty|BCBSTX HMO|||||60.75||| 84425|EAP|0300|THIAMINE (B1)|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||60.75||| 84425|EAP|0300|THIAMINE (B1)|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||60.75||| 84432|EAP|0300|THYROGLOBULIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1.41||| 84436|EAP|0300|T4 THYROXINE|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.63||||||| 84436|EAP|0300|T4 THYROXINE|Medicare|MEDICARE ACUTE|2.63||||61.50||| 84436|EAP|0300|T4 THYROXINE|Managed Medicaid|MEDICAID SUPERIOR|2.63||||61.50||| 84436|EAP|0300|T4 THYROXINE|Managed Medicaid|MEDICAID AMERIGROUP|||||61.50||| 84436|EAP|0300|T4 THYROXINE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||61.50||| 84436|EAP|0300|T4 THYROXINE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||61.50||| 84436|EAP|0300|T4 THYROXINE|Medicaid|MEDICAID|2.63||||61.50||| 84436|EAP|0300|T4 THYROXINE|Medicaid|MEDICAID HMO|||||61.50||| 84436|EAP|0300|T4 THYROXINE|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||61.50||| 84436|EAP|0300|T4 THYROXINE|Blue Cross PPO Specialty|BCBSTX PPO|||||61.50||| 84436|EAP|0300|T4 THYROXINE|Humana Medicare Advantage|HUMANA MA|||||61.50||| 84436|EAP|0300|T4 THYROXINE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||61.50||| 84436|EAP|0300|T4 THYROXINE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||61.50||| 84436|EAP|0300|T4 THYROXINE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||61.50||| 84439|EAP|0300|T4 FREE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||80.50||| 84439|EAP|0300|T4 FREE|Blue Cross HMO Specialty|BCBSTX HMO|345.50||||80.50||| 84439|EAP|0300|T4 FREE|Aetna|BOON CHAPMAN|||||80.50||| 84439|EAP|0300|T4 FREE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||80.50||| 84439|EAP|0300|T4 FREE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||80.50||| 84439|EAP|0300|T4 FREE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||80.50||| 84439|EAP|0300|T4 FREE|Blue Cross PPO Specialty|BCBSTX OTHER|||||80.50||| 84439|EAP|0300|T4 FREE|Humana Medicare Advantage|HUMANA MA|345.50||||80.50||| 84439|EAP|0300|T4 FREE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||80.50||| 84439|EAP|0300|T4 FREE|Cigna|CIGNA|||||80.50||| 84439|EAP|0300|T4 FREE|Medicaid|MEDICAID TEXAS CHILDRENS|||||80.50||| 84439|EAP|0300|T4 FREE|Managed Medicaid|MEDICAID SUPERIOR|345.50||||80.50||| 84439|EAP|0300|T4 FREE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||80.50||| 84439|EAP|0300|T4 FREE|Blue Cross PPO Specialty|BCBSTX PPO|345.50||||80.50||| 84439|EAP|0300|T4 FREE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|345.50||||80.50||| 84439|EAP|0300|T4 FREE|Medicaid|MEDICAID|345.50||||80.50||| 84439|EAP|0300|T4 FREE|Managed Medicare|HEALTHSPRING MA|||||80.50||| 84439|EAP|0300|T4 FREE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||80.50||| 84439|EAP|0300|T4 FREE|Aetna|AETNA PPO|||||80.50||| 84439|EAP|0300|T4 FREE|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||80.50||| 84439|EAP|0300|T4 FREE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||80.50||| 84439|EAP|0300|T4 FREE|Medicaid|MEDICAID HMO|||||80.50||| 84439|EAP|0300|T4 FREE|Managed Medicare|BCBS MEDICARE PPO MA|||||80.50||| 84439|EAP|0300|T4 FREE|Aetna|AETNA OTHER|||||80.50||| 84439|EAP|0300|T4 FREE|NON CONTRACTED|COMMERCIAL OTHER 1|||||80.50||| 84439|EAP|0300|T4 FREE|Medicare|MEDICARE ACUTE|345.50||||80.50||| 84439|EAP|0300|T4 FREE|PHCS|HUMANA INSURANCE|||||80.50||| 84439|EAP|0300|T4 FREE|Rusk State Hospital|RUSK STATE HOSP|345.50||||||| 84439|EAP|0300|T4 FREE|Managed Medicaid|MEDICAID AMERIGROUP|||||80.50||| 84439|EAP|0300|T4 FREE|Tricare|TRICARE EAST REGION|||||80.50||| 84439|EAP|0300|T4 FREE|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||80.50||| 84439|EAP|0300|T4 FREE|UTMB|UTMB CORRECTIONAL MANAGED CARE|345.50||||||| 84439|EAP|0300|T4 FREE|United Healthcare|UNITED HEALTHCARE|||||80.50||| 84439|EAP|0300|T4 FREE|United Healthcare|UNITED HEALTHCARE OTHER|||||80.50||| 84439|EAP|0300|T4 FREE|Veterans Affairs|VETERANS ADMINISTRATION|345.50||||||| 84439|EAP|0300|T4 FREE|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||80.50||| 84439|EAP|0300|T4 FREE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|345.50||||80.50||| 84439|EAP|0300|T4 FREE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|345.50||||80.50||| 84439|EAP|0300|T4 FREE|United Medicare Advantage|UHC MEDICARE GOLD MA|345.50||||80.50||| 84439|EAP|0300|T4 FREE|United Healthcare|TML GROUP BENEFITS|||||80.50||| 84439|EAP|0300|T4 FREE|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||80.50||| 84439|EAP|0300|T4 FREE|Workers Compensation|UT EMPLOYEE INJURY|345.50||||||| 84439|EAP|0300|T4 FREE|Aenta Medicare Advantage|AETNA MEDICARE MA|345.50||||80.50||| 84439|EAP|0300|T4 FREE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||80.50||| 84442|EAP|0300|THYROXINE BINDING GLOBULI|Blue Cross PPO Specialty|BCBSTX PPO|||||132.25||| 84442|EAP|0300|THYROXINE BINDING GLOBULI|United Medicare Advantage|UHC MEDICARE GOLD MA|||||132.25||| 84443|EAP|0300|THYROID STIMULATING HORMO|UTMB|UTMB CORRECTIONAL MANAGED CARE|643.75||||643.75||| 84443|EAP|0300|THYROID STIMULATING HORMO|Medicare|MEDICARE PART B ONLY IP|643.75||||||| 84443|EAP|0300|THYROID STIMULATING HORMO|NON CONTRACTED|COMMERCIAL OTHER 2|||||3.97||| 84443|EAP|0300|THYROID STIMULATING HORMO|PHCS|HUMANA INSURANCE|||||150.25||| 84443|EAP|0300|THYROID STIMULATING HORMO|Tricare|TRICARE EAST REGION|||||150.25||| 84443|EAP|0300|THYROID STIMULATING HORMO|Rusk State Hospital|RUSK STATE HOSP|643.75||||3.97||| 84443|EAP|0300|THYROID STIMULATING HORMO|Medicaid|COUNTY INDIGENT HEALTH OTHER|643.75||||150.25||| 84443|EAP|0300|THYROID STIMULATING HORMO|Medicaid|MEDICAID|643.75||||150.25||| 84443|EAP|0300|THYROID STIMULATING HORMO|Managed Medicare|HEALTHSPRING MA|643.75||||150.25||| 84443|EAP|0300|THYROID STIMULATING HORMO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|643.75||||150.25||| 84443|EAP|0300|THYROID STIMULATING HORMO|Managed Medicaid|MEDICAID SUPERIOR|643.75||||150.25||| 84443|EAP|0300|THYROID STIMULATING HORMO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|643.75||||150.25||| 84443|EAP|0300|THYROID STIMULATING HORMO|Managed Medicaid|MEDICAID AMERIGROUP|||||150.25||| 84443|EAP|0300|THYROID STIMULATING HORMO|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||150.25||| 84443|EAP|0300|THYROID STIMULATING HORMO|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||150.25||| 84443|EAP|0300|THYROID STIMULATING HORMO|Medicaid|MEDICAID HMO|||||150.25||| 84443|EAP|0300|THYROID STIMULATING HORMO|Medicaid|MEDICAID TEXAS CHILDRENS|||||150.25||| 84443|EAP|0300|THYROID STIMULATING HORMO|United Healthcare|UNITED HEALTHCARE OTHER|||||150.25||| 84443|EAP|0300|THYROID STIMULATING HORMO|Veterans Affairs|VETERANS ADMINISTRATION|643.75||||3.97||| 84443|EAP|0300|THYROID STIMULATING HORMO|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||150.25||| 84443|EAP|0300|THYROID STIMULATING HORMO|United Medicare Advantage|UHC MEDICARE GOLD MA|643.75||||150.25||| 84443|EAP|0300|THYROID STIMULATING HORMO|United Medicare Advantage|AARP UHC WEST COMPLETE MA|643.75||||150.25||| 84443|EAP|0300|THYROID STIMULATING HORMO|Managed Medicare|BCBS MEDICARE PPO MA|||||150.25||| 84443|EAP|0300|THYROID STIMULATING HORMO|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||150.25||| 84443|EAP|0300|THYROID STIMULATING HORMO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|643.75||||150.25||| 84443|EAP|0300|THYROID STIMULATING HORMO|United Healthcare|UNITED HEALTHCARE|643.75||||150.25||| 84443|EAP|0300|THYROID STIMULATING HORMO|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|643.75||||150.25||| 84443|EAP|0300|THYROID STIMULATING HORMO|Workers Compensation|UT EMPLOYEE INJURY|643.75||||||| 84443|EAP|0300|THYROID STIMULATING HORMO|Workers Compensation|WORKERS COMPENSATION OTHER|643.75||||150.25||| 84443|EAP|0300|THYROID STIMULATING HORMO|Medicare|MEDICARE ACUTE|643.75||||150.25||| 84443|EAP|0300|THYROID STIMULATING HORMO|United Healthcare|TML GROUP BENEFITS|643.75||||150.25||| 84443|EAP|0300|THYROID STIMULATING HORMO|United Healthcare|UMR UNITED MEDICAL RESOURCES|643.75||||150.25||| 84443|EAP|0300|THYROID STIMULATING HORMO|Aetna|BOON CHAPMAN|||||150.25||| 84443|EAP|0300|THYROID STIMULATING HORMO|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||150.25||| 84443|EAP|0300|THYROID STIMULATING HORMO|NON CONTRACTED|COMMERCIAL OTHER 1|643.75||||150.25||| 84443|EAP|0300|THYROID STIMULATING HORMO|Blue Cross HMO Specialty|BCBSTX HMO|643.75||||150.25||| 84443|EAP|0300|THYROID STIMULATING HORMO|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|643.75||||150.25||| 84443|EAP|0300|THYROID STIMULATING HORMO|Access Direct Platinum|HEALTHFIRST TPA UMR|||||150.25||| 84443|EAP|0300|THYROID STIMULATING HORMO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|643.75||||150.25||| 84443|EAP|0300|THYROID STIMULATING HORMO|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|643.75||||150.25||| 84443|EAP|0300|THYROID STIMULATING HORMO|Aetna|AETNA OTHER|||||150.25||| 84443|EAP|0300|THYROID STIMULATING HORMO|Aetna|AETNA PPO|643.75||||150.25||| 84443|EAP|0300|THYROID STIMULATING HORMO|Aenta Medicare Advantage|AETNA MEDICARE MA|643.75||||150.25||| 84443|EAP|0300|THYROID STIMULATING HORMO|Cigna|CIGNA|643.75||||150.25||| 84443|EAP|0300|THYROID STIMULATING HORMO|Blue Cross PPO Specialty|BCBSTX PPO|643.75||||150.25||| 84443|EAP|0300|THYROID STIMULATING HORMO|Blue Cross PPO Specialty|BCBSTX OTHER|||||150.25||| 84443|EAP|0300|THYROID STIMULATING HORMO|Cigna|CIGNA|||||150.25||| 84443|EAP|0300|THYROID STIMULATING HORMO|Humana Medicare Advantage|HUMANA MA|643.75||||150.25||| 84443|EAP|0300|THYROID STIMULATING HORMO|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||150.25||| 84445|EAP|0300|THYROID STIMULATING ANTIB|Blue Cross PPO Specialty|BCBSTX PPO|||||454.50||| 84445|EAP|0300|THYROID STIMULATING ANTIB|Managed Medicaid|MEDICAID SUPERIOR|||||454.50||| 84445|EAP|0300|THYROID STIMULATING ANTIB|Managed Medicaid|MEDICAID AMERIGROUP|||||454.50||| 84445|EAP|0300|THYROID STIMULATING ANTIB|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||454.50||| 84445|EAP|0300|THYROID STIMULATING ANTIB|Medicaid|MEDICAID|||||454.50||| 84445|EAP|0300|THYROID STIMULATING ANTIB|Medicare|MEDICARE ACUTE|||||454.50||| 84446|EAP|0301|VITAMIN E|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||126.75||| 84446|EAP|0301|VITAMIN E|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||126.75||| 84450|EAP|0301|AST (SGOT)|United Medicare Advantage|AARP UHC WEST COMPLETE MA|197.75||||||| 84450|EAP|0301|AST (SGOT)|Humana Medicare Advantage|HUMANA MA|||||197.75||| 84450|EAP|0301|AST (SGOT)|Blue Cross PPO Specialty|BCBSTX PPO|||||197.75||| 84450|EAP|0301|AST (SGOT)|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||197.75||| 84450|EAP|0301|AST (SGOT)|Medicare|MEDICARE ACUTE|||||46.25||| 84450|EAP|0301|AST (SGOT)|Medicaid|MEDICAID|||||46.25||| 84450|EAP|0301|AST (SGOT)|Managed Medicaid|MEDICAID SUPERIOR|||||46.25||| 84460|EAP|0301|ALT (SGPT)|Managed Medicaid|MEDICAID SUPERIOR|||||47.25||| 84460|EAP|0301|ALT (SGPT)|Medicare|MEDICARE ACUTE|||||47.25||| 84460|EAP|0301|ALT (SGPT)|Blue Cross PPO Specialty|BCBSTX PPO|||||202.75||| 84460|EAP|0301|ALT (SGPT)|Humana Medicare Advantage|HUMANA MA|||||202.75||| 84460|EAP|0301|ALT (SGPT)|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||202.75||| 84460|EAP|0301|ALT (SGPT)|United Medicare Advantage|AARP UHC WEST COMPLETE MA|202.75||||||| 84466|EAP|0301|TRANSFERRIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||82.25||| 84466|EAP|0301|TRANSFERRIN|Humana Medicare Advantage|HUMANA MA|||||82.25||| 84466|EAP|0301|TRANSFERRIN|Medicare|MEDICARE ACUTE|352.50||||82.25||| 84466|EAP|0301|TRANSFERRIN|Medicaid|MEDICAID|352.50||||82.25||| 84466|EAP|0301|TRANSFERRIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||82.25||| 84466|EAP|0301|TRANSFERRIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||82.25||| 84466|EAP|0301|TRANSFERRIN|Managed Medicaid|MEDICAID AMERIGROUP|||||82.25||| 84466|EAP|0301|TRANSFERRIN|Managed Medicaid|MEDICAID SUPERIOR|||||82.25||| 84466|EAP|0301|TRANSFERRIN|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||82.25||| 84478|EAP|0300|TRIGLYCERIDES|Managed Medicare|HEALTHSPRING MA|220.50||||||| 84478|EAP|0300|TRIGLYCERIDES|Humana Medicare Advantage|HUMANA MA|220.50||||||| 84479|EAP|0300|T3 UPTAKE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||57.75||| 84479|EAP|0300|T3 UPTAKE|Blue Cross PPO Specialty|BCBSTX PPO|||||57.75||| 84479|EAP|0300|T3 UPTAKE|Humana Medicare Advantage|HUMANA MA|||||57.75||| 84479|EAP|0300|T3 UPTAKE|Medicare|MEDICARE ACUTE|247.75||||57.75||| 84479|EAP|0300|T3 UPTAKE|Managed Medicaid|MEDICAID AMERIGROUP|||||57.75||| 84479|EAP|0300|T3 UPTAKE|Managed Medicaid|MEDICAID SUPERIOR|||||57.75||| 84479|EAP|0300|T3 UPTAKE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||57.75||| 84479|EAP|0300|T3 UPTAKE|Medicaid|MEDICAID|||||57.75||| 84480|EAP|0301|TOTAL T3|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||126.75||| 84480|EAP|0301|TOTAL T3|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||126.75||| 84480|EAP|0301|TOTAL T3|Medicaid|MEDICAID|5.43||||126.75||| 84480|EAP|0301|TOTAL T3|NON CONTRACTED|COMMERCIAL OTHER 1|||||126.75||| 84480|EAP|0301|TOTAL T3|Medicare|MEDICARE ACUTE|||||126.75||| 84480|EAP|0301|TOTAL T3|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||126.75||| 84480|EAP|0301|TOTAL T3|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||126.75||| 84480|EAP|0301|TOTAL T3|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||126.75||| 84480|EAP|0301|TOTAL T3|Humana Medicare Advantage|HUMANA MA|||||126.75||| 84480|EAP|0301|TOTAL T3|Blue Cross PPO Specialty|BCBSTX PPO|||||126.75||| 84480|EAP|0301|TOTAL T3|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||126.75||| 84480|EAP|0301|TOTAL T3|Blue Cross HMO Specialty|BCBSTX HMO|||||126.75||| 84481|EAP|0300|T3, FREE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||151.50||| 84481|EAP|0300|T3, FREE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||151.50||| 84481|EAP|0300|T3, FREE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||151.50||| 84481|EAP|0300|T3, FREE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||151.50||| 84481|EAP|0300|T3, FREE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||151.50||| 84481|EAP|0300|T3, FREE|Blue Cross PPO Specialty|BCBSTX PPO|649.25||||151.50||| 84481|EAP|0300|T3, FREE|Blue Cross PPO Specialty|BCBSTX OTHER|||||151.50||| 84481|EAP|0300|T3, FREE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||151.50||| 84481|EAP|0300|T3, FREE|Cigna|CIGNA|||||151.50||| 84481|EAP|0300|T3, FREE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||151.50||| 84481|EAP|0300|T3, FREE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|649.25||||151.50||| 84481|EAP|0300|T3, FREE|Workers Compensation|UT EMPLOYEE INJURY|649.25||||||| 84481|EAP|0300|T3, FREE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||151.50||| 84481|EAP|0300|T3, FREE|United Healthcare|TML GROUP BENEFITS|||||151.50||| 84481|EAP|0300|T3, FREE|Humana Medicare Advantage|HUMANA MA|649.25||||151.50||| 84481|EAP|0300|T3, FREE|Blue Cross HMO Specialty|BCBSTX HMO|649.25||||151.50||| 84481|EAP|0300|T3, FREE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||151.50||| 84481|EAP|0300|T3, FREE|United Healthcare|UNITED HEALTHCARE OTHER|||||151.50||| 84481|EAP|0300|T3, FREE|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||151.50||| 84481|EAP|0300|T3, FREE|UTMB|UTMB CORRECTIONAL MANAGED CARE|649.25||||||| 84481|EAP|0300|T3, FREE|Rusk State Hospital|RUSK STATE HOSP|649.25||||||| 84481|EAP|0300|T3, FREE|Medicare|MEDICARE ACUTE|649.25||||151.50||| 84481|EAP|0300|T3, FREE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||151.50||| 84481|EAP|0300|T3, FREE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|649.25||||151.50||| 84481|EAP|0300|T3, FREE|Managed Medicaid|MEDICAID SUPERIOR|||||151.50||| 84481|EAP|0300|T3, FREE|Managed Medicaid|MEDICAID AMERIGROUP|||||151.50||| 84481|EAP|0300|T3, FREE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||151.50||| 84481|EAP|0300|T3, FREE|Medicaid|MEDICAID|649.25||||151.50||| 84481|EAP|0300|T3, FREE|Managed Medicare|HEALTHSPRING MA|||||151.50||| 84481|EAP|0300|T3, FREE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||151.50||| 84482|EAP|0300|T3 REVERSE|Blue Cross HMO Specialty|BCBSTX HMO|||||68.75||| 84484|EAP|0301|TROPONIN I|Medicaid|MEDICAID|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|Managed Medicare|HOSPICE OF EAST TEXAS|377.25||||||| 84484|EAP|0301|TROPONIN I|Managed Medicare|BCBS MEDICARE PPO MA|||||377.25||| 84484|EAP|0301|TROPONIN I|Managed Medicaid|MEDICAID SUPERIOR|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|Medicaid|COUNTY INDIGENT HEALTH OTHER|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|Medicaid|SUPERIOR HEALTHPLAN CHIP|377.25||||0.88||| 84484|EAP|0301|TROPONIN I|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||377.25||| 84484|EAP|0301|TROPONIN I|Tricare|TRICARE EAST REGION|||||377.25||| 84484|EAP|0301|TROPONIN I|NON CONTRACTED|COMMERCIAL OTHER 2|||||377.25||| 84484|EAP|0301|TROPONIN I|NON CONTRACTED|COMMERCIAL OTHER 1|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|Medicare|MEDICARE PART B ONLY IP|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|Rusk State Hospital|RUSK STATE HOSP|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|Veterans Affairs|VETERANS ADMINISTRATION|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|PHCS|HUMANA INSURANCE|||||377.25||| 84484|EAP|0301|TROPONIN I|United Healthcare|UNITED HEALTHCARE OTHER|||||377.25||| 84484|EAP|0301|TROPONIN I|United Healthcare|UNITED HEALTHCARE|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|United Healthcare|UNITED HEALTHCARE|||||377.25||| 84484|EAP|0301|TROPONIN I|United Healthcare|UMR UNITED MEDICAL RESOURCES|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||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|United Healthcare|TML GROUP BENEFITS|377.25||||||| 84484|EAP|0301|TROPONIN I|United Medicare Advantage|UHC MEDICARE GOLD MA|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|United Healthcare|GEHA|||||377.25||| 84484|EAP|0301|TROPONIN I|United Medicare Advantage|AARP UHC WEST COMPLETE MA|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|377.25||||||| 84484|EAP|0301|TROPONIN I|Workers Compensation|WORKERS COMPENSATION OTHER|||||377.25||| 84484|EAP|0301|TROPONIN I|Managed Medicaid|MEDICAID AMERIGROUP|||||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|Humana Medicare Advantage|HUMANA MA|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|Managed Medicare|HEALTHSPRING MA|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|Blue Cross PPO Specialty|BCBSTX OTHER|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|Blue Cross PPO Specialty|BCBSTX PPO|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|Cigna|CIGNA|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|Cigna|CIGNA|||||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 TPA UTH UMR|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|Aetna|AETNA PPO|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|Aetna|AETNA OTHER|||||0.88||| 84484|EAP|0301|TROPONIN I|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|377.25||||377.25||| 84484|EAP|0301|TROPONIN I|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||377.25||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|151.25||||35.25||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|Blue Cross HMO Specialty|BCBSTX HMO|151.25||||35.25||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||35.25||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|151.25||||35.25||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|Aenta Medicare Advantage|AETNA MEDICARE MA|||||35.25||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|Cigna|CIGNA|||||151.25||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|Humana Medicare Advantage|HUMANA MA|151.25||||35.25||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|Blue Cross PPO Specialty|BCBSTX PPO|151.25||||35.25||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|United Medicare Advantage|UHC MEDICARE GOLD MA|||||35.25||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|151.25||||35.25||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|United Healthcare|TML GROUP BENEFITS|||||35.25||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|United Healthcare|UNITED HEALTHCARE OTHER|||||35.25||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||35.25||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|United Medicare Advantage|AARP UHC WEST COMPLETE MA|151.25||||35.25||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|Veterans Affairs|VETERANS ADMINISTRATION|||||35.25||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|Medicare|MEDICARE ACUTE|151.25||||35.25||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|NON CONTRACTED|COMMERCIAL OTHER 1|151.25||||35.25||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||35.25||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|Managed Medicare|HEALTHSPRING MA|||||35.25||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|Managed Medicare|BCBS MEDICARE PPO MA|||||35.25||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||35.25||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|151.25||||35.25||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|Managed Medicaid|MEDICAID SUPERIOR|151.25||||93.25||| 84520|EAP|0301|BUN BLOOD UREA NITROGEN S|Medicaid|MEDICAID|151.25||||35.25||| 84550|EAP|0300|URIC ACID BLOOD|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||40.25||| 84550|EAP|0300|URIC ACID BLOOD|Managed Medicare|HEALTHSPRING MA|||||40.25||| 84550|EAP|0300|URIC ACID BLOOD|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||40.25||| 84550|EAP|0300|URIC ACID BLOOD|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||40.25||| 84550|EAP|0300|URIC ACID BLOOD|Managed Medicare|BCBS MEDICARE PPO MA|||||40.25||| 84550|EAP|0300|URIC ACID BLOOD|Medicaid|MEDICAID HMO|||||106.75||| 84550|EAP|0300|URIC ACID BLOOD|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||173.25||| 84550|EAP|0300|URIC ACID BLOOD|Managed Medicaid|MEDICAID AMERIGROUP|173.25||||40.25||| 84550|EAP|0300|URIC ACID BLOOD|Managed Medicaid|MEDICAID SUPERIOR|173.25||||173.25||| 84550|EAP|0300|URIC ACID BLOOD|NON CONTRACTED|COMMERCIAL OTHER 1|||||40.25||| 84550|EAP|0300|URIC ACID BLOOD|UTMB|UTMB CORRECTIONAL MANAGED CARE|173.25||||||| 84550|EAP|0300|URIC ACID BLOOD|Tricare|TRICARE EAST REGION|||||40.25||| 84550|EAP|0300|URIC ACID BLOOD|Medicare|MEDICARE ACUTE|173.25||||40.25||| 84550|EAP|0300|URIC ACID BLOOD|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|173.25||||||| 84550|EAP|0300|URIC ACID BLOOD|Veterans Affairs|VETERANS ADMINISTRATION|||||40.25||| 84550|EAP|0300|URIC ACID BLOOD|United Medicare Advantage|UHC MEDICARE GOLD MA|173.25||||40.25||| 84550|EAP|0300|URIC ACID BLOOD|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||40.25||| 84550|EAP|0300|URIC ACID BLOOD|United Healthcare|UNITED HEALTHCARE OTHER|173.25||||173.25||| 84550|EAP|0300|URIC ACID BLOOD|Medicaid|MEDICAID|173.25||||40.25||| 84550|EAP|0300|URIC ACID BLOOD|United Healthcare|UNITED HEALTHCARE|||||40.25||| 84550|EAP|0300|URIC ACID BLOOD|United Healthcare|TML GROUP BENEFITS|||||40.25||| 84550|EAP|0300|URIC ACID BLOOD|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||40.25||| 84550|EAP|0300|URIC ACID BLOOD|United Healthcare|UNITED HEALTHCARE|||||173.25||| 84550|EAP|0300|URIC ACID BLOOD|Blue Cross PPO Specialty|BCBSTX PPO|173.25||||40.25||| 84550|EAP|0300|URIC ACID BLOOD|Blue Cross PPO Specialty|BCBSTX OTHER|||||40.25||| 84550|EAP|0300|URIC ACID BLOOD|Humana Medicare Advantage|HUMANA MA|||||40.25||| 84550|EAP|0300|URIC ACID BLOOD|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||40.25||| 84550|EAP|0300|URIC ACID BLOOD|Cigna|CIGNA|||||173.25||| 84550|EAP|0300|URIC ACID BLOOD|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||40.25||| 84550|EAP|0300|URIC ACID BLOOD|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||173.25||| 84550|EAP|0300|URIC ACID BLOOD|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||40.25||| 84550|EAP|0300|URIC ACID BLOOD|Blue Cross HMO Specialty|BCBSTX HMO|173.25||||40.25||| 84550|EAP|0300|URIC ACID BLOOD|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||40.25||| 84550|EAP|0300|URIC ACID BLOOD|Aenta Medicare Advantage|AETNA MEDICARE MA|173.25||||||| 84586|EAP|0300|VASOACTIVE INTESTIONAL PO|Medicare|MEDICARE ACUTE|534.50||||||| 84588|EAP|0300|VASOPRESSIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||303.50||| 84588|EAP|0300|VASOPRESSIN|Managed Medicaid|MEDICAID AMERIGROUP|||||303.50||| 84590|EAP|0301|VITAMIN A (RETINOL)|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||103.75||| 84591|EAP|0301|NIACIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||444.25||| 84597|EAP|0301|VITAMIN K|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||60.75||| 84630|EAP|0300|ZINC SERUM|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||101.75||| 84681|EAP|0300|C-PEPTIDE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1.86||| 84681|EAP|0300|C-PEPTIDE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1.86||| 84681|EAP|0300|C-PEPTIDE|Medicaid|MEDICAID|||||1.86||| 84681|EAP|0300|C-PEPTIDE|Medicare|MEDICARE ACUTE|||||1.86||| 84681|EAP|0300|C-PEPTIDE|Blue Cross PPO Specialty|BCBSTX PPO|||||1.86||| 84681|EAP|0300|C-PEPTIDE|Humana Medicare Advantage|HUMANA MA|||||1.86||| 84681|EAP|0300|C-PEPTIDE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1.86||| 84681|EAP|0300|C-PEPTIDE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.86||| 84681|EAP|0300|C-PEPTIDE|Blue Cross HMO Specialty|BCBSTX HMO|||||1.86||| 84681|EAP|0300|C-PEPTIDE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.86||| 84681|EAP|0300|C-PEPTIDE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.86||| 84681|EAP|0300|C-PEPTIDE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1.86||| 84681|EAP|0300|C-PEPTIDE|United Healthcare|TML GROUP BENEFITS|||||1.86||| 84681|EAP|0300|C-PEPTIDE|United Healthcare|UNITED HEALTHCARE|||||1.86||| 84702|EAP|0300|HCG QUANTITATIVE|Workers Compensation|WORKERS COMPENSATION OTHER|||||3.35||| 84702|EAP|0300|HCG QUANTITATIVE|United Healthcare|UNITED HEALTHCARE OTHER|||||0.78||| 84702|EAP|0300|HCG QUANTITATIVE|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||3.35||| 84702|EAP|0300|HCG QUANTITATIVE|Blue Cross HMO Specialty|BCBSTX HMO|||||0.78||| 84702|EAP|0300|HCG QUANTITATIVE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.78||| 84702|EAP|0300|HCG QUANTITATIVE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||3.35||| 84702|EAP|0300|HCG QUANTITATIVE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.35||||0.78||| 84702|EAP|0300|HCG QUANTITATIVE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||0.78||| 84702|EAP|0300|HCG QUANTITATIVE|Humana Medicare Advantage|HUMANA MA|||||0.78||| 84702|EAP|0300|HCG QUANTITATIVE|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.78||| 84702|EAP|0300|HCG QUANTITATIVE|Blue Cross PPO Specialty|BCBSTX PPO|||||0.78||| 84702|EAP|0300|HCG QUANTITATIVE|United Healthcare|UNITED HEALTHCARE|||||0.78||| 84702|EAP|0300|HCG QUANTITATIVE|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||0.78||| 84702|EAP|0300|HCG QUANTITATIVE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.78||| 84702|EAP|0300|HCG QUANTITATIVE|Managed Medicaid|MEDICAID AMERIGROUP|||||0.78||| 84702|EAP|0300|HCG QUANTITATIVE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||3.35||| 84702|EAP|0300|HCG QUANTITATIVE|Medicaid|MEDICAID|3.35||||3.35||| 84702|EAP|0300|HCG QUANTITATIVE|Managed Medicaid|MEDICAID SUPERIOR|3.35||||0.78||| 84702|EAP|0300|HCG QUANTITATIVE|Medicaid|MEDICAID HMO|||||0.78||| 84702|EAP|0300|HCG QUANTITATIVE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||206.50||| 84702|EAP|0300|HCG QUANTITATIVE|NON CONTRACTED|COMMERCIAL OTHER 1|||||206.50||| 84702|EAP|0301|HCG TUMOR MARKER,QUANT|Medicare|MEDICARE ACUTE|||||0.78||| 84702|EAP|0300|HCG QUANTITATIVE|Tricare|TRICARE EAST REGION|||||0.78||| 84702|EAP|0300|HCG QUANTITATIVE|Medicare|MEDICARE ACUTE|3.35||||0.78||| 84703|EAP|0300|PREGNANCY TEST SERUM|Rusk State Hospital|RUSK STATE HOSP|||||67.25||| 84703|EAP|0300|PREGNANCY TEST SERUM|NON CONTRACTED|COMMERCIAL OTHER 1|||||67.25||| 84703|EAP|0300|PREGNANCY TEST SERUM|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||2.88||| 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|Managed Medicaid|MEDICAID AMERIGROUP|||||2.88||| 84703|EAP|0300|PREGNANCY TEST SERUM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.88||||2.88||| 84703|EAP|0300|PREGNANCY TEST SERUM|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||67.25||| 84703|EAP|0300|PREGNANCY TEST SERUM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||2.88||| 84703|EAP|0300|PREGNANCY TEST SERUM|Humana Medicare Advantage|HUMANA MA|||||2.88||| 84703|EAP|0300|PREGNANCY TEST SERUM|Blue Cross PPO Specialty|BCBSTX PPO|2.88||||2.88||| 84703|EAP|0300|PREGNANCY TEST SERUM|Blue Cross PPO Specialty|BCBSTX OTHER|||||177.63||| 84703|EAP|0300|PREGNANCY TEST SERUM|Cigna|CIGNA|||||67.25||| 84703|EAP|0300|PREGNANCY TEST SERUM|Medicare|MEDICARE ACUTE|||||2.88||| 84703|EAP|0300|PREGNANCY TEST SERUM|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2.88||| 84703|EAP|0300|PREGNANCY TEST SERUM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.88||||2.88||| 84703|EAP|0300|PREGNANCY TEST SERUM|Blue Cross HMO Specialty|BCBSTX HMO|||||2.88||| 84703|EAP|0300|PREGNANCY TEST SERUM|Aetna|AETNA PPO|||||2.88||| 84703|EAP|0300|PREGNANCY TEST SERUM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||2.88||| 84703|EAP|0300|PREGNANCY TEST SERUM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.88||| 84703|EAP|0300|PREGNANCY TEST SERUM|United Healthcare|UNITED HEALTHCARE OTHER|2.88||||177.63||| 84703|EAP|0300|PREGNANCY TEST SERUM|United Healthcare|UNITED HEALTHCARE|||||2.88||| 84703|EAP|0300|PREGNANCY TEST SERUM|United Medicare Advantage|UHC MEDICARE GOLD MA|||||67.25||| 84703|EAP|0300|PREGNANCY TEST SERUM|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||177.63||| 84703|EAP|0300|PREGNANCY TEST SERUM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2.88||| 84703|EAP|0300|PREGNANCY TEST SERUM|United Healthcare|UNITED HEALTHCARE|||||67.25||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|United Healthcare|UMR UNITED MEDICAL RESOURCES|64.50||||64.50||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|United Healthcare|UNITED HEALTHCARE|64.50||||64.50||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Veterans Affairs|VETERANS ADMINISTRATION|64.50||||64.50||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|64.50||||30.75||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|United Medicare Advantage|AARP UHC WEST COMPLETE MA|64.50||||47.63||| 85007|EAP|0305||United Medicare Advantage|UHC MEDICARE GOLD MA|||||129.75||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Workers Compensation|UT EMPLOYEE INJURY|64.50||||||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||64.50||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|United Healthcare|UNITED HEALTHCARE OTHER|64.50||||30.75||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Workers Compensation|WORKERS COMPENSATION OTHER|64.50||||64.50||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|United Healthcare|TML GROUP BENEFITS|||||30.75||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|64.50||||64.50||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Aenta Medicare Advantage|AETNA MEDICARE MA|64.50||||64.50||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Aetna|AETNA OTHER|64.50||||||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|64.50||||30.75||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Aetna|AETNA PPO|64.50||||64.50||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|64.50||||64.50||| 85007|EAP|0305||Aenta Medicare Advantage|AETNA MEDICARE MA|||||129.75||| 85007|EAP|0305||Humana Medicare Advantage|HUMANA MA|||||129.75||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Blue Cross HMO Specialty|BCBSTX HMO|64.50||||47.63||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Cigna|CIGNA|||||64.50||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|64.50||||30.75||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Brinson Benefits|THE HEALTH PLAN SMITH CO|64.50||||||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Blue Cross PPO Specialty|BCBSTX PPO|64.50||||64.50||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Blue Cross PPO Specialty|BCBSTX OTHER|64.50||||64.50||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Cigna|CIGNA|64.50||||30.75||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|United Healthcare|UNITED HEALTHCARE|64.50||||30.75||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Humana Medicare Advantage|HUMANA MA|64.50||||30.75||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||30.75||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Managed Medicaid|MEDICAID SUPERIOR|64.50||||64.50||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|64.50||||30.75||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Managed Medicaid|MEDICAID AMERIGROUP|64.50||||64.50||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|64.50||||64.50||| 85007|EAP|0305||United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||129.75||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|United Medicare Advantage|UHC MEDICARE GOLD MA|64.50||||64.50||| 85007|EAP|0305||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||129.75||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Medicaid|MEDICAID HMO|||||47.63||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Medicaid|MEDICAID TEXAS CHILDRENS|||||64.50||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Managed Medicare|HEALTHSPRING MA|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|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||64.50||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Medicaid|MEDICAID|64.50||||64.50||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Medicaid|COUNTY INDIGENT HEALTH OTHER|64.50||||64.50||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Rusk State Hospital|RUSK STATE HOSP|64.50||||64.50||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Tricare|TRICARE EAST REGION|||||64.50||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|NON CONTRACTED|COMMERCIAL OTHER 1|64.50||||30.75||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|Medicare|MEDICARE ACUTE|64.50||||64.50||| 85007|EAP|0305||Medicare|MEDICARE ACUTE|||||129.75||| 85007|EAP|0300|MANUAL DIFFERENTIAL WBC|UTMB|UTMB CORRECTIONAL MANAGED CARE|64.50||||64.50||| 85014|EAP|0300|HEMATOCRIT|UTMB|UTMB CORRECTIONAL MANAGED CARE|90.75||||||| 85014|EAP|0300|HEMATOCRIT|Medicare|MEDICARE ACUTE|90.75||||21.25||| 85014|EAP|0300|HEMATOCRIT|NON CONTRACTED|COMMERCIAL OTHER 1|90.75||||90.75||| 85014|EAP|0300|HEMATOCRIT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|90.75||||90.75||| 85014|EAP|0300|HEMATOCRIT|Managed Medicaid|MEDICAID AMERIGROUP|90.75||||0.56||| 85014|EAP|0300|HEMATOCRIT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||21.25||| 85014|EAP|0300|HEMATOCRIT|Managed Medicare|HEALTHSPRING MA|90.75||||||| 85014|EAP|0300|HEMATOCRIT|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||21.25||| 85014|EAP|0300|HEMATOCRIT|Medicaid|MEDICAID|90.75||||21.25||| 85014|EAP|0300|HEMATOCRIT|Humana Medicare Advantage|HUMANA MA|90.75||||21.25||| 85014|EAP|0300|HEMATOCRIT|Managed Medicaid|MEDICAID SUPERIOR|90.75||||21.25||| 85014|EAP|0300|HEMATOCRIT|Blue Cross PPO Specialty|BCBSTX PPO|90.75||||90.75||| 85014|EAP|0300|HEMATOCRIT|Blue Cross PPO Specialty|BCBSTX OTHER|||||90.75||| 85014|EAP|0300|HEMATOCRIT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|90.75||||21.25||| 85014|EAP|0300|HEMATOCRIT|Aenta Medicare Advantage|AETNA MEDICARE MA|90.75||||21.25||| 85014|EAP|0300|HEMATOCRIT|Aetna|AETNA PPO|||||21.25||| 85014|EAP|0300|HEMATOCRIT|Blue Cross HMO Specialty|BCBSTX HMO|||||90.75||| 85014|EAP|0300|HEMATOCRIT|United Healthcare|UNITED HEALTHCARE|||||0.56||| 85014|EAP|0300|HEMATOCRIT|United Medicare Advantage|UHC MEDICARE GOLD MA|||||21.25||| 85014|EAP|0300|HEMATOCRIT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|90.75||||||| 85014|EAP|0300|HEMATOCRIT|United Medicare Advantage|AARP UHC WEST COMPLETE MA|90.75||||21.25||| 85014|EAP|0300|HEMATOCRIT|Veterans Affairs|VETERANS ADMINISTRATION|90.75||||||| 85014|EAP|0300|HEMATOCRIT|Workers Compensation|WORKERS COMPENSATION OTHER|90.75||||||| 85014|EAP|0300|HEMATOCRIT|United Healthcare|UNITED HEALTHCARE OTHER|90.75||||||| 85018|EAP|0300|HEMOGLOBIN|United Healthcare|UNITED HEALTHCARE|||||0.56||| 85018|EAP|0300|HEMOGLOBIN|United Healthcare|UNITED HEALTHCARE|||||21.25||| 85018|EAP|0300|HEMOGLOBIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|90.75||||||| 85018|EAP|0300|HEMOGLOBIN|United Medicare Advantage|UHC MEDICARE GOLD MA|||||21.25||| 85018|EAP|0300|HEMOGLOBIN|Veterans Affairs|VETERANS ADMINISTRATION|90.75||||||| 85018|EAP|0300|HEMOGLOBIN|United Healthcare|UNITED HEALTHCARE OTHER|90.75||||21.25||| 85018|EAP|0300|HEMOGLOBIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|90.75||||||| 85018|EAP|0300|HEMOGLOBIN|Aenta Medicare Advantage|AETNA MEDICARE MA|90.75||||21.25||| 85018|EAP|0300|HEMOGLOBIN|Blue Cross HMO Specialty|BCBSTX HMO|90.75||||90.75||| 85018|EAP|0300|HEMOGLOBIN|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||21.25||| 85018|EAP|0300|HEMOGLOBIN|United Medicare Advantage|AARP UHC WEST COMPLETE MA|90.75||||||| 85018|EAP|0300|HEMOGLOBIN|Blue Cross PPO Specialty|BCBSTX PPO|90.75||||90.75||| 85018|EAP|0300|HEMOGLOBIN|Blue Cross PPO Specialty|BCBSTX OTHER|||||90.75||| 85018|EAP|0300|HEMOGLOBIN|Humana Medicare Advantage|HUMANA MA|90.75||||90.75||| 85018|EAP|0300|HEMOGLOBIN|Medicaid|MEDICAID|90.75||||21.25||| 85018|EAP|0300|HEMOGLOBIN|Managed Medicaid|MEDICAID SUPERIOR|90.75||||21.25||| 85018|EAP|0300|HEMOGLOBIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||21.25||| 85018|EAP|0300|HEMOGLOBIN|Managed Medicaid|MEDICAID AMERIGROUP|90.75||||21.25||| 85018|EAP|0300|HEMOGLOBIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|90.75||||90.75||| 85018|EAP|0300|HEMOGLOBIN|Medicaid|MEDICAID HMO|||||21.25||| 85018|EAP|0300|HEMOGLOBIN|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||21.25||| 85018|EAP|0300|HEMOGLOBIN|NON CONTRACTED|COMMERCIAL OTHER 1|||||90.75||| 85018|EAP|0300|HEMOGLOBIN|Medicare|MEDICARE ACUTE|90.75||||21.25||| 85018|EAP|0300|HEMOGLOBIN|UTMB|UTMB CORRECTIONAL MANAGED CARE|90.75||||||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||297.75||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|NON CONTRACTED|COMMERCIAL OTHER 2|297.75||||69.50||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|PHCS|HUMANA INSURANCE|||||69.50||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|NON CONTRACTED|COMMERCIAL OTHER 1|297.75||||69.50||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Medicare|MEDICARE ACUTE|297.75||||69.50||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Tricare|TRICARE EAST REGION|297.75||||69.50||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|UTMB|UTMB CORRECTIONAL MANAGED CARE|297.75||||297.75||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Rusk State Hospital|RUSK STATE HOSP|297.75||||297.75||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Managed Medicaid|MEDICAID SUPERIOR|297.75||||69.50||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|297.75||||69.50||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Managed Medicaid|MEDICAID AMERIGROUP|297.75||||69.50||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Managed Medicare|HOSPICE OF EAST TEXAS|297.75||||69.50||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Managed Medicare|BCBS MEDICARE PPO MA|||||69.50||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Managed Medicare|HEALTHSPRING MA|297.75||||69.50||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Medicaid|MEDICAID TEXAS CHILDRENS|||||69.50||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Medicaid|MEDICAID PCCM|||||297.75||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Medicaid|SUPERIOR HEALTHPLAN CHIP|297.75||||69.50||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Medicaid|MOLINA HEALTHCARE OF TEXAS|297.75||||69.50||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Medicaid|MEDICAID HMO|||||69.50||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Medicaid|COUNTY INDIGENT HEALTH OTHER|297.75||||297.75||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Cigna|CIGNA|297.75||||||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Blue Cross PPO Specialty|BCBSTX OTHER|297.75||||69.50||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|297.75||||69.50||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Cigna|CIGNA|||||297.75||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Medicaid|MEDICAID|297.75||||297.75||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Brinson Benefits|THE HEALTH PLAN SMITH CO|297.75||||||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Humana Medicare Advantage|HUMANA MA|297.75||||69.50||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Blue Cross PPO Specialty|BCBSTX PPO|297.75||||69.50||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Cigna|CIGNA|297.75||||69.50||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|297.75||||69.50||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Blue Cross HMO Specialty|BCBSTX HMO|297.75||||69.50||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|297.75||||69.50||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|297.75||||69.50||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Aenta Medicare Advantage|AETNA MEDICARE MA|297.75||||69.50||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Managed Medicaid|MEDICAID UNITED HEALTHCARE|297.75||||69.50||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|297.75||||69.50||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Aetna|AETNA PPO|297.75||||69.50||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Aetna|BOON CHAPMAN|||||69.50||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Aetna|AETNA OTHER|297.75||||69.50||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|297.75||||69.50||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Access Direct Platinum|HEALTHFIRST TPA UMR|||||69.50||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Workers Compensation|UT EMPLOYEE INJURY|297.75||||||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|297.75||||297.75||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Medicare|MEDICARE PART B ONLY IP|297.75||||69.50||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|297.75||||297.75||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|United Healthcare|UNITED HEALTHCARE OTHER|297.75||||69.50||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|United Healthcare|UNITED HEALTHCARE|297.75||||69.50||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|United Healthcare|UMR UNITED MEDICAL RESOURCES|297.75||||297.75||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|United Healthcare|TML GROUP BENEFITS|297.75||||69.50||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|United Healthcare|GOLDEN RULE|||||69.50||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|United Healthcare|GEHA|||||183.63||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|United Healthcare|AARP|||||69.50||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|297.75||||69.50||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|United Medicare Advantage|AARP UHC WEST COMPLETE MA|297.75||||69.50||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|United Medicare Advantage|UHC MEDICARE GOLD MA|297.75||||69.50||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Veterans Affairs|VETERANS ADMINISTRATION|297.75||||297.75||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|Workers Compensation|WORKERS COMPENSATION OTHER|297.75||||297.75||| 85025|EAP|0305|CBC/INDICES & COMPLETE AU|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|297.75||||69.50||| 85027|EAP|0300|CBC/NO DIFF|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|247.75||||||| 85027|EAP|0300|CBC/NO DIFF|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|247.75||||57.75||| 85027|EAP|0300|CBC/NO DIFF|United Medicare Advantage|AARP UHC WEST COMPLETE MA|247.75||||247.75||| 85027|EAP|0300|CBC/NO DIFF|United Healthcare|GOLDEN RULE|||||57.75||| 85027|EAP|0300|CBC/NO DIFF|United Medicare Advantage|UHC MEDICARE GOLD MA|247.75||||247.75||| 85027|EAP|0300|CBC/NO DIFF|Workers Compensation|WORKERS COMPENSATION OTHER|247.75||||247.75||| 85027|EAP|0300|CBC/NO DIFF|United Healthcare|UNITED HEALTHCARE OTHER|247.75||||152.75||| 85027|EAP|0300|CBC/NO DIFF|United Healthcare|UNITED HEALTHCARE|247.75||||247.75||| 85027|EAP|0300|CBC/NO DIFF|United Healthcare|UNITED HEALTHCARE|247.75||||||| 85027|EAP|0300|CBC/NO DIFF|United Healthcare|UMR UNITED MEDICAL RESOURCES|247.75||||247.75||| 85027|EAP|0300|CBC/NO DIFF|Workers Compensation|UT EMPLOYEE INJURY|247.75||||||| 85027|EAP|0300|CBC/NO DIFF|Veterans Affairs|VETERANS ADMINISTRATION|247.75||||247.75||| 85027|EAP|0300|CBC/NO DIFF|Access Direct Platinum|HEALTHFIRST TPA UMR|||||247.75||| 85027|EAP|0300|CBC/NO DIFF|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|247.75||||57.75||| 85027|EAP|0300|CBC/NO DIFF|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|247.75||||247.75||| 85027|EAP|0300|CBC/NO DIFF|Blue Cross HMO Specialty|BCBSTX HMO|247.75||||247.75||| 85027|EAP|0300|CBC/NO DIFF|Aetna|AETNA OTHER|247.75||||||| 85027|EAP|0300|CBC/NO DIFF|Aetna|AETNA PPO|247.75||||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|Aenta Medicare Advantage|AETNA MEDICARE MA|247.75||||247.75||| 85027|EAP|0300|CBC/NO DIFF|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|247.75||||57.75||| 85027|EAP|0300|CBC/NO DIFF|Humana Medicare Advantage|HUMANA MA|247.75||||247.75||| 85027|EAP|0300|CBC/NO DIFF|Brinson Benefits|THE HEALTH PLAN SMITH CO|247.75||||||| 85027|EAP|0300|CBC/NO DIFF|Blue Cross PPO Specialty|BCBSTX PPO|247.75||||247.75||| 85027|EAP|0300|CBC/NO DIFF|Blue Cross PPO Specialty|BCBSTX OTHER|247.75||||247.75||| 85027|EAP|0300|CBC/NO DIFF|Cigna|CIGNA|||||247.75||| 85027|EAP|0300|CBC/NO DIFF|United Healthcare|TML GROUP BENEFITS|247.75||||||| 85027|EAP|0300|CBC/NO DIFF|Cigna|CIGNA|247.75||||57.75||| 85027|EAP|0300|CBC/NO DIFF|Managed Medicaid|MEDICAID SUPERIOR|247.75||||247.75||| 85027|EAP|0300|CBC/NO DIFF|Managed Medicaid|MEDICAID AMERIGROUP|247.75||||247.75||| 85027|EAP|0300|CBC/NO DIFF|Managed Medicaid|MEDICAID UNITED HEALTHCARE|247.75||||247.75||| 85027|EAP|0300|CBC/NO DIFF|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|247.75||||152.75||| 85027|EAP|0300|CBC/NO DIFF|Medicaid|MEDICAID|247.75||||247.75||| 85027|EAP|0300|CBC/NO DIFF|Managed Medicare|HEALTHSPRING MA|247.75||||247.75||| 85027|EAP|0300|CBC/NO DIFF|Managed Medicare|HOSPICE OF EAST TEXAS|247.75||||||| 85027|EAP|0300|CBC/NO DIFF|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||247.75||| 85027|EAP|0300|CBC/NO DIFF|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|247.75||||247.75||| 85027|EAP|0300|CBC/NO DIFF|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||152.75||| 85027|EAP|0300|CBC/NO DIFF|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||247.75||| 85027|EAP|0300|CBC/NO DIFF|Medicaid|MEDICAID HMO|||||247.75||| 85027|EAP|0300|CBC/NO DIFF|Medicaid|MEDICAID TEXAS CHILDRENS|||||152.75||| 85027|EAP|0300|CBC/NO DIFF|Medicaid|COUNTY INDIGENT HEALTH OTHER|247.75||||247.75||| 85027|EAP|0300|CBC/NO DIFF|UTMB|UTMB CORRECTIONAL MANAGED CARE|247.75||||247.75||| 85027|EAP|0300|CBC/NO DIFF|NON CONTRACTED|COMMERCIAL OTHER 1|247.75||||152.75||| 85027|EAP|0300|CBC/NO DIFF|Medicare|MEDICARE ACUTE|247.75||||247.75||| 85027|EAP|0300|CBC/NO DIFF|Rusk State Hospital|RUSK STATE HOSP|247.75||||247.75||| 85027|EAP|0300|CBC/NO DIFF|Tricare|TRICARE EAST REGION|||||247.75||| 85044|EAP|0305|RETICULOCYTE COUNT|Rusk State Hospital|RUSK STATE HOSP|||||38.50||| 85044|EAP|0305|RETICULOCYTE COUNT|NON CONTRACTED|COMMERCIAL OTHER 1|164.50||||||| 85044|EAP|0305|RETICULOCYTE COUNT|Managed Medicare|HEALTHSPRING MA|164.50||||||| 85044|EAP|0305|RETICULOCYTE COUNT|Medicaid|MEDICAID|164.50||||||| 85044|EAP|0305|RETICULOCYTE COUNT|Managed Medicaid|MEDICAID SUPERIOR|164.50||||38.50||| 85044|EAP|0305|RETICULOCYTE COUNT|Medicare|MEDICARE ACUTE|164.50||||164.50||| 85044|EAP|0305|RETICULOCYTE COUNT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||164.50||| 85044|EAP|0305|RETICULOCYTE COUNT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|164.50||||101.50||| 85044|EAP|0305|RETICULOCYTE COUNT|Managed Medicaid|MEDICAID AMERIGROUP|164.50||||101.50||| 85044|EAP|0305|RETICULOCYTE COUNT|Blue Cross PPO Specialty|BCBSTX OTHER|||||164.50||| 85044|EAP|0305|RETICULOCYTE COUNT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||164.50||| 85044|EAP|0305|RETICULOCYTE COUNT|Blue Cross PPO Specialty|BCBSTX PPO|164.50||||38.50||| 85044|EAP|0305|RETICULOCYTE COUNT|Blue Cross HMO Specialty|BCBSTX HMO|164.50||||164.50||| 85044|EAP|0305|RETICULOCYTE COUNT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|164.50||||||| 85044|EAP|0305|RETICULOCYTE COUNT|Workers Compensation|WORKERS COMPENSATION OTHER|164.50||||||| 85044|EAP|0305|RETICULOCYTE COUNT|United Medicare Advantage|UHC MEDICARE GOLD MA|164.50||||||| 85044|EAP|0305|RETICULOCYTE COUNT|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||38.50||| 85044|EAP|0305|RETICULOCYTE COUNT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||164.50||| 85048|EAP|0300|WBC|Medicare|MEDICARE ACUTE|||||22.75||| 85049|EAP|0305|PLATELET COUNT|United Healthcare|UNITED HEALTHCARE OTHER|1.71||||0.40||| 85049|EAP|0305|PLATELET COUNT|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||0.40||| 85049|EAP|0305|PLATELET COUNT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.40||| 85049|EAP|0305|PLATELET COUNT|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.40||| 85049|EAP|0305|PLATELET COUNT|Blue Cross HMO Specialty|BCBSTX HMO|1.71||||||| 85049|EAP|0305|PLATELET COUNT|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.40||| 85049|EAP|0305|PLATELET COUNT|Blue Cross PPO Specialty|BCBSTX PPO|||||0.40||| 85049|EAP|0305|PLATELET COUNT|Humana Medicare Advantage|HUMANA MA|||||0.40||| 85049|EAP|0305|PLATELET COUNT|Managed Medicaid|MEDICAID SUPERIOR|1.71||||||| 85049|EAP|0305|PLATELET COUNT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.40||| 85049|EAP|0305|PLATELET COUNT|Managed Medicare|HEALTHSPRING MA|||||0.40||| 85049|EAP|0305|PLATELET COUNT|Medicare|MEDICARE ACUTE|||||0.40||| 85049|EAP|0305|PLATELET COUNT|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.40||| 85060|EAP|0305|PERIPHERAL SMEAR TO PATHO|NON CONTRACTED|COMMERCIAL OTHER 1|||||129.75||| 85060|EAP|0305|PERIPHERAL SMEAR TO PATHO|UTMB|UTMB CORRECTIONAL MANAGED CARE|129.75||||||| 85060|EAP|0305|PERIPHERAL SMEAR TO PATHO|Medicare|MEDICARE ACUTE|129.75||||||| 85060|EAP|0305|PERIPHERAL SMEAR TO PATHO|Managed Medicaid|MEDICAID AMERIGROUP|||||129.75||| 85060|EAP|0305|PERIPHERAL SMEAR TO PATHO|Tricare|TRICARE EAST REGION|||||129.75||| 85060|EAP|0305|PERIPHERAL SMEAR TO PATHO|Managed Medicaid|MEDICAID SUPERIOR|||||129.75||| 85060|EAP|0305|PERIPHERAL SMEAR TO PATHO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|129.75||||129.75||| 85060|EAP|0305|PERIPHERAL SMEAR TO PATHO|Medicaid|MEDICAID TEXAS CHILDRENS|||||129.75||| 85060|EAP|0305|PERIPHERAL SMEAR TO PATHO|Medicaid|MEDICAID|129.75||||129.75||| 85060|EAP|0305|PERIPHERAL SMEAR TO PATHO|Medicaid|SUPERIOR HEALTHPLAN CHIP|129.75||||||| 85060|EAP|0305|PERIPHERAL SMEAR TO PATHO|Humana Medicare Advantage|HUMANA MA|129.75||||||| 85060|EAP|0305|PERIPHERAL SMEAR TO PATHO|Blue Cross PPO Specialty|BCBSTX PPO|||||129.75||| 85060|EAP|0305|PERIPHERAL SMEAR TO PATHO|Blue Cross PPO Specialty|BCBSTX OTHER|||||129.75||| 85060|EAP|0305|PERIPHERAL SMEAR TO PATHO|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||129.75||| 85060|EAP|0305|PERIPHERAL SMEAR TO PATHO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||129.75||| 85060|EAP|0305|PERIPHERAL SMEAR TO PATHO|United Medicare Advantage|UHC MEDICARE GOLD MA|129.75||||||| 85060|EAP|0305|PERIPHERAL SMEAR TO PATHO|United Medicare Advantage|AARP UHC WEST COMPLETE MA|129.75||||129.75||| 85210|EAP|0305|FACTOR II ASSAY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.16||| 85220|EAP|0305|FACTOR V ASSAY|Managed Medicaid|MEDICAID SUPERIOR|||||157.75||| 85240|EAP|0305|FACTOR VIII ASSAY|Humana Medicare Advantage|HUMANA MA|||||57.25||| 85240|EAP|0305|FACTOR VIII ASSAY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||57.25||| 85246|EAP|0305|F8, VWF, FACTOR ANTIGEN|NON CONTRACTED|COMMERCIAL OTHER 1|||||73.25||| 85247|EAP|0305|VON WILLEBRAND FACTOR MUL|Aetna|AETNA OTHER|||||313.75||| 85250|EAP|0305|FACTOR IX|Managed Medicaid|MEDICAID SUPERIOR|729.25||||||| 85250|EAP|0305|FACTOR IX|Humana Medicare Advantage|HUMANA MA|||||170.25||| 85250|EAP|0305|FACTOR IX|Cigna|CIGNA|||||170.25||| 85250|EAP|0305|FACTOR IX|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||170.25||| 85260|EAP|0305|FACTOR X ASSAY|Managed Medicaid|MEDICAID AMERIGROUP|||||1.60||| 85280|EAP|0300|FACTOR XII|Humana Medicare Advantage|HUMANA MA|||||1.73||| 85300|EAP|0305|ANTITHROMBIN III ACTIVITY|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1.06||| 85300|EAP|0305|ANTITHROMBIN III ACTIVITY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.06||| 85300|EAP|0305|ANTITHROMBIN III ACTIVITY|Cigna|CIGNA|454.25||||||| 85300|EAP|0305|ANTITHROMBIN III ACTIVITY|Blue Cross PPO Specialty|BCBSTX PPO|||||1.06||| 85301|EAP|0300|ANTITHROMBIN III ANTIGEN|Managed Medicaid|MEDICAID SUPERIOR|414.25||||||| 85302|EAP|0305|PROTEIN C ANTIGEN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||107.50||| 85302|EAP|0305|PROTEIN C ANTIGEN|Medicaid|MEDICAID|||||107.50||| 85302|EAP|0305|PROTEIN C ANTIGEN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||107.50||| 85302|EAP|0305|PROTEIN C ANTIGEN|Managed Medicaid|MEDICAID SUPERIOR|460.25||||||| 85306|EAP|0300|PROTEIN S ACTIVITY,FREE|Managed Medicaid|MEDICAID SUPERIOR|444.25||||||| 85306|EAP|0300|PROTEIN S ACTIVITY,FREE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||444.25||| 85306|EAP|0300|PROTEIN C ACTIVITY|Blue Cross PPO Specialty|BCBSTX PPO|||||123.50||| 85306|EAP|0305|PROTEIN S ACTIVITY/TOTAL|Blue Cross PPO Specialty|BCBSTX PPO|||||103.75||| 85306|EAP|0300|PROTEIN C ACTIVITY|Cigna|CIGNA|529.50||||||| 85306|EAP|0305|PROTEIN S ACTIVITY/TOTAL|Cigna|CIGNA|444.25||||||| 85306|EAP|0300|PROTEIN C ACTIVITY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||123.50||| 85306|EAP|0300|PROTEIN S ACTIVITY,FREE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||123.25||| 85306|EAP|0305|PROTEIN S ACTIVITY/TOTAL|Aenta Medicare Advantage|AETNA MEDICARE MA|||||103.75||| 85306|EAP|0305|PROTEIN S ACTIVITY/TOTAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||103.75||| 85306|EAP|0300|PROTEIN C ACTIVITY|Aenta Medicare Advantage|AETNA MEDICARE MA|||||123.50||| 85307|EAP|0305|PROTEIN C RESISTANCE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||123.25||| 85379|EAP|0305|D-DIMER|Tricare|TRICARE EAST REGION|||||2.73||| 85379|EAP|0305|D-DIMER|NON CONTRACTED|COMMERCIAL OTHER 1|2.73||||2.73||| 85379|EAP|0305|D-DIMER|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.73||||2.73||| 85379|EAP|0305|D-DIMER|Medicare|MEDICARE ACUTE|2.73||||2.73||| 85379|EAP|0305|D-DIMER|Rusk State Hospital|RUSK STATE HOSP|2.73||||2.73||| 85379|EAP|0305|D-DIMER|Managed Medicare|HEALTHSPRING MA|2.73||||||| 85379|EAP|0305|D-DIMER|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.73||||2.73||| 85379|EAP|0305|D-DIMER|Managed Medicaid|MEDICAID AMERIGROUP|||||2.73||| 85379|EAP|0305|D-DIMER|Managed Medicaid|MEDICAID SUPERIOR|2.73||||2.73||| 85379|EAP|0305|D-DIMER|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||63.75||| 85379|EAP|0305|D-DIMER|Medicaid|MEDICAID|2.73||||2.73||| 85379|EAP|0305|D-DIMER|Medicaid|SUPERIOR HEALTHPLAN CHIP|2.73||||2.73||| 85379|EAP|0305|D-DIMER|United Medicare Advantage|UHC MEDICARE GOLD MA|2.73||||2.73||| 85379|EAP|0305|D-DIMER|United Healthcare|UNITED HEALTHCARE OTHER|||||168.38||| 85379|EAP|0305|D-DIMER|United Healthcare|UNITED HEALTHCARE|2.73||||63.75||| 85379|EAP|0305|D-DIMER|Medicaid|MEDICAID HMO|||||2.73||| 85379|EAP|0305|D-DIMER|United Healthcare|UNITED HEALTHCARE|||||2.73||| 85379|EAP|0305|D-DIMER|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||2.73||| 85379|EAP|0305|D-DIMER|United Healthcare|GEHA|||||2.73||| 85379|EAP|0305|D-DIMER|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.73||||2.73||| 85379|EAP|0305|D-DIMER|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.73||||2.73||| 85379|EAP|0305|D-DIMER|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.73||||||| 85379|EAP|0305|D-DIMER|United Medicare Advantage|AARP UHC WEST COMPLETE MA|2.73||||2.73||| 85379|EAP|0305|D-DIMER|Veterans Affairs|VETERANS ADMINISTRATION|||||2.73||| 85379|EAP|0305|D-DIMER|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||2.73||| 85379|EAP|0305|D-DIMER|Workers Compensation|UT EMPLOYEE INJURY|2.73||||||| 85379|EAP|0305|D-DIMER|Workers Compensation|WORKERS COMPENSATION OTHER|2.73||||2.73||| 85379|EAP|0305|D-DIMER|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2.73||| 85379|EAP|0305|D-DIMER|Cigna|CIGNA|||||2.73||| 85379|EAP|0305|D-DIMER|Humana Medicare Advantage|HUMANA MA|2.73||||2.73||| 85379|EAP|0305|D-DIMER|Blue Cross PPO Specialty|BCBSTX PPO|2.73||||2.73||| 85379|EAP|0305|D-DIMER|Cigna|CIGNA|2.73||||2.73||| 85379|EAP|0305|D-DIMER|Blue Cross PPO Specialty|BCBSTX OTHER|2.73||||2.73||| 85379|EAP|0305|D-DIMER|Blue Cross HMO Specialty|BCBSTX HMO|2.73||||2.73||| 85379|EAP|0305|D-DIMER|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||2.73||| 85379|EAP|0305|D-DIMER|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.73||||2.73||| 85379|EAP|0305|D-DIMER|Aenta Medicare Advantage|AETNA MEDICARE MA|2.73||||2.73||| 85379|EAP|0305|D-DIMER|Aetna|AETNA OTHER|2.73||||||| 85379|EAP|0305|D-DIMER|Aetna|AETNA PPO|||||2.73||| 85379|EAP|0305|D-DIMER|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.73||| 85384|EAP|0300|FIBRINOGEN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|325.25||||0.76||| 85384|EAP|0300|FIBRINOGEN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.76||| 85384|EAP|0300|FIBRINOGEN|Blue Cross PPO Specialty|BCBSTX PPO|||||0.76||| 85384|EAP|0300|FIBRINOGEN|United Healthcare|UNITED HEALTHCARE OTHER|325.25||||0.76||| 85384|EAP|0300|FIBRINOGEN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|325.25||||||| 85384|EAP|0300|FIBRINOGEN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|325.25||||||| 85384|EAP|0300|FIBRINOGEN|Managed Medicaid|MEDICAID AMERIGROUP|325.25||||||| 85384|EAP|0300|FIBRINOGEN|Managed Medicaid|MEDICAID SUPERIOR|325.25||||||| 85384|EAP|0300|FIBRINOGEN|Medicaid|MEDICAID|325.25||||325.25||| 85384|EAP|0300|FIBRINOGEN|Medicaid|MEDICAID TEXAS CHILDRENS|||||325.25||| 85384|EAP|0300|FIBRINOGEN|Tricare|TRICARE EAST REGION|||||325.25||| 85384|EAP|0300|FIBRINOGEN|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.76||| 85384|EAP|0300|FIBRINOGEN|Medicare|MEDICARE ACUTE|325.25||||||| 85384|EAP|0300|FIBRINOGEN|UTMB|UTMB CORRECTIONAL MANAGED CARE|325.25||||||| 854|DRG||INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W CC|Humana Medicare Advantage|HUMANA MA|146,052.80|17734.28|17734.28|17734.28|||| 85460|EAP|0305|FETAL CELL COUNT KLEINHAU|Medicaid|MEDICAID TEXAS CHILDRENS|||||296.50||| 85461|EAP|0300|FETAL SCREEN|United Healthcare|UNITED HEALTHCARE|245.25||||||| 85461|EAP|0300|FETAL SCREEN|Blue Cross HMO Specialty|BCBSTX HMO|245.25||||||| 85461|EAP|0300|FETAL SCREEN|Managed Medicaid|MEDICAID SUPERIOR|245.25||||||| 85461|EAP|0300|FETAL SCREEN|Managed Medicaid|MEDICAID AMERIGROUP|245.25||||||| 85461|EAP|0300|FETAL SCREEN|Medicaid|MEDICAID|245.25||||||| 85520|EAP|0305|ANTI-XA|Managed Medicaid|MEDICAID AMERIGROUP|||||1.17||| 856|DRG||POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W MCC|Medicare|MEDICARE ACUTE|105,870.80|33079.82|33079.82|33079.82|||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|150.50||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Humana Medicare Advantage|HUMANA MA|150.50||||150.50||| 85610|EAP|0300|CLINIC-PT/INR|Humana Medicare Advantage|HUMANA MA|150.50||||0.46||| 85610|EAP|0305||Humana Medicare Advantage|HUMANA MA|||||35.25||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Blue Cross PPO Specialty|BCBSTX PPO|150.50||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Blue Cross PPO Specialty|BCBSTX OTHER|150.50||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Cigna|CIGNA|150.50||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|150.50||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|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)|Blue Cross HMO Specialty|BCBSTX HMO|150.50||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Aetna|AETNA OTHER|||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Aetna|AETNA PPO|150.50||||0.35||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|150.50||||150.50||| 85610|EAP|0300|CLINIC-PT/INR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|150.50||||0.46||| 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|150.50||||150.50||| 85610|EAP|0300|CLINIC-PT/INR|United Medicare Advantage|AARP UHC WEST COMPLETE MA|150.50||||0.46||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|United Medicare Advantage|UHC MEDICARE GOLD MA|150.50||||150.50||| 85610|EAP|0300|CLINIC-PT/INR|United Medicare Advantage|UHC MEDICARE GOLD MA|150.50||||0.46||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Workers Compensation|WORKERS COMPENSATION OTHER|150.50||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|United Healthcare|UNITED HEALTHCARE OTHER|150.50||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|United Healthcare|UNITED HEALTHCARE|150.50||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||92.75||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|United Healthcare|UMR UNITED MEDICAL RESOURCES|150.50||||150.50||| 85610|EAP|0300|CLINIC-PT/INR|United Healthcare|UNITED HEALTHCARE OTHER|150.50||||0.46||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|United Healthcare|GEHA|||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Medicaid|MEDICAID TEXAS CHILDRENS|||||150.50||| 85610|EAP|0305||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||35.25||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|150.50||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Managed Medicare|HOSPICE OF EAST TEXAS|150.50||||||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Managed Medicaid|MEDICAID SUPERIOR|150.50||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Veterans Affairs|VETERANS ADMINISTRATION|150.50||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Managed Medicaid|MEDICAID UNITED HEALTHCARE|150.50||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|150.50||||150.50||| 85610|EAP|0300|CLINIC-PT/INR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|150.50||||0.46||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Managed Medicaid|MEDICAID AMERIGROUP|150.50||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Aenta Medicare Advantage|AETNA MEDICARE MA|150.50||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|150.50||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Medicaid|SUPERIOR HEALTHPLAN CHIP|150.50||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Medicaid|COUNTY INDIGENT HEALTH OTHER|150.50||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Medicaid|MEDICAID HMO|||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Medicaid|MOLINA HEALTHCARE OF TEXAS|150.50||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Medicaid|MEDICAID PCCM|||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Medicaid|MEDICAID|150.50||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Managed Medicare|HEALTHSPRING MA|150.50||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Cigna|CIGNA|||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|NON CONTRACTED|COMMERCIAL OTHER 1|150.50||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Tricare|TRICARE EAST REGION|150.50||||0.35||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|NON CONTRACTED|COMMERCIAL OTHER 2|||||150.50||| 85610|EAP|0305||NON CONTRACTED|COMMERCIAL OTHER 1|||||35.25||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|PHCS|HUMANA INSURANCE|||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Medicare|MEDICARE PART B ONLY IP|150.50||||||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Medicare|MEDICARE ACUTE|150.50||||150.50||| 85610|EAP|0300|CLINIC-PT/INR|Medicare|MEDICARE ACUTE|150.50||||0.46||| 85610|EAP|0305||Medicare|MEDICARE ACUTE|||||35.25||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|UTMB|UTMB CORRECTIONAL MANAGED CARE|150.50||||150.50||| 85610|EAP|0300|PROTHROMBIN TIME (PT)|Rusk State Hospital|RUSK STATE HOSP|150.50||||150.50||| 85611|EAP|0305|PROTHROMBIN TIME MIXING S|NON CONTRACTED|COMMERCIAL OTHER 1|150.75||||||| 85611|EAP|0305|PROTHROMBIN TIME MIXING S|United Medicare Advantage|UHC MEDICARE GOLD MA|150.75||||||| 85611|EAP|0305|PROTHROMBIN TIME MIXING S|Humana Medicare Advantage|HUMANA MA|150.75||||||| 85613|EAP|0305|RUSSELL VIPER VENOM|Blue Cross HMO Specialty|BCBSTX HMO|||||62.50||| 85613|EAP|0305|RUSSELL VIPER VENOM|Aenta Medicare Advantage|AETNA MEDICARE MA|||||62.50||| 85613|EAP|0305|RUSSELL VIPER VENOM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||62.50||| 85613|EAP|0305|RUSSELL VIPER VENOM|Humana Medicare Advantage|HUMANA MA|||||62.50||| 85613|EAP|0305|RUSSELL VIPER VENOM|Cigna|CIGNA|||||62.50||| 85613|EAP|0305|RUSSELL VIPER VENOM|Blue Cross PPO Specialty|BCBSTX PPO|||||62.50||| 85613|EAP|0305|RUSSELL VIPER VENOM|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||62.50||| 85613|EAP|0305|RUSSELL VIPER VENOM|United Healthcare|UNITED HEALTHCARE|||||62.50||| 85613|EAP|0305|RUSSELL VIPER VENOM|Managed Medicaid|MEDICAID SUPERIOR|2.68||||62.50||| 85613|EAP|0305|RUSSELL VIPER VENOM|Medicaid|MEDICAID|||||62.50||| 85613|EAP|0305|RUSSELL VIPER VENOM|Medicare|MEDICARE ACUTE|||||62.50||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Tricare|TRICARE EAST REGION|||||24.25||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|UTMB|UTMB CORRECTIONAL MANAGED CARE|103.25||||103.25||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Medicare|MEDICARE ACUTE|103.25||||24.25||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|NON CONTRACTED|COMMERCIAL OTHER 1|103.25||||24.25||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Managed Medicaid|MEDICAID AMERIGROUP|||||24.25||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Managed Medicaid|MEDICAID UNITED HEALTHCARE|103.25||||24.25||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Managed Medicaid|MEDICAID SUPERIOR|103.25||||24.25||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|103.25||||24.25||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Medicaid|SUPERIOR HEALTHPLAN CHIP|103.25||||63.75||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Medicaid|MEDICAID|103.25||||24.25||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Managed Medicare|BCBS MEDICARE PPO MA|||||24.25||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Managed Medicare|HEALTHSPRING MA|103.25||||24.25||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Medicaid|COUNTY INDIGENT HEALTH OTHER|103.25||||||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Medicaid|MEDICAID HMO|||||24.25||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Medicaid|MEDICAID TEXAS CHILDRENS|||||24.25||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||103.25||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|United Healthcare|UNITED HEALTHCARE OTHER|||||24.25||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||24.25||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|United Medicare Advantage|UHC MEDICARE GOLD MA|103.25||||24.25||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|United Medicare Advantage|AARP UHC WEST COMPLETE MA|103.25||||24.25||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|103.25||||24.25||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Veterans Affairs|VETERANS ADMINISTRATION|||||24.25||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Workers Compensation|UT EMPLOYEE INJURY|103.25||||||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|United Healthcare|UNITED HEALTHCARE|||||24.25||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Workers Compensation|WORKERS COMPENSATION OTHER|103.25||||103.25||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Blue Cross PPO Specialty|BCBSTX PPO|||||24.25||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Blue Cross PPO Specialty|BCBSTX OTHER|103.25||||24.25||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Brinson Benefits|THE HEALTH PLAN SMITH CO|103.25||||||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Cigna|CIGNA|||||63.75||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Rusk State Hospital|RUSK STATE HOSP|103.25||||103.25||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Humana Medicare Advantage|HUMANA MA|103.25||||24.25||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|103.25||||24.25||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Cigna|CIGNA|||||103.25||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||24.25||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|103.25||||24.25||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||24.25||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Aenta Medicare Advantage|AETNA MEDICARE MA|103.25||||63.75||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Blue Cross HMO Specialty|BCBSTX HMO|||||24.25||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Access Direct Platinum|HEALTHFIRST TPA UMR|||||24.25||| 85652|EAP|0305|ERYTHROCYTE SEDIMENATION|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||24.25||| 85660|EAP|0305|SICKLE CELL SCREEN|Managed Medicaid|MEDICAID AMERIGROUP|||||49.25||| 85670|EAP|0300|THROMBIN TIME|Blue Cross HMO Specialty|BCBSTX HMO|||||0.49||| 85670|EAP|0300|THROMBIN TIME|Humana Medicare Advantage|HUMANA MA|||||0.49||| 85670|EAP|0300|THROMBIN TIME|Blue Cross PPO Specialty|BCBSTX PPO|||||0.49||| 85670|EAP|0300|THROMBIN TIME|Medicare|MEDICARE ACUTE|||||0.49||| 85670|EAP|0300|THROMBIN TIME|Managed Medicaid|MEDICAID SUPERIOR|163.25||||||| 857|DRG||POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W CC|Humana Medicare Advantage|HUMANA MA|53,351.70|16321.42|26359.93|16321.42|||| 857|DRG||POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS W O.R. PROC W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|37,575.05|26359.93|26359.93|16321.42|||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.30||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Managed Medicaid|MEDICAID AMERIGROUP|2.30||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.30||||2.30||| 85730|EAP|0305||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.30||||57.75||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Managed Medicaid|MEDICAID SUPERIOR|2.30||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Medicaid|MOLINA HEALTHCARE OF TEXAS|2.30||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.30||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Managed Medicare|HOSPICE OF EAST TEXAS|2.30||||||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Managed Medicare|HEALTHSPRING MA|2.30||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Medicaid|MEDICAID PCCM|||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Medicaid|MEDICAID TEXAS CHILDRENS|||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Medicaid|SUPERIOR HEALTHPLAN CHIP|2.30||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Medicaid|MEDICAID HMO|||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|NON CONTRACTED|COMMERCIAL OTHER 2|||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Medicare|MEDICARE ACUTE|2.30||||2.30||| 85730|EAP|0305||Medicare|MEDICARE ACUTE|2.30||||57.75||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|NON CONTRACTED|COMMERCIAL OTHER 1|2.30||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Medicare|MEDICARE PART B ONLY IP|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|Rusk State Hospital|RUSK STATE HOSP|2.30||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Workers Compensation|WORKERS COMPENSATION OTHER|2.30||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|2.30||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|PHCS|HUMANA INSURANCE|||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|United Medicare Advantage|UHC MEDICARE GOLD MA|2.30||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|United Healthcare|UNITED HEALTHCARE OTHER|2.30||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Tricare|TRICARE EAST REGION|2.30||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|United Healthcare|UNITED HEALTHCARE|2.30||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|United Healthcare|UMR UNITED MEDICAL RESOURCES|2.30||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Medicaid|MEDICAID|2.30||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|United Healthcare|GEHA|||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Veterans Affairs|VETERANS ADMINISTRATION|2.30||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.30||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|United Medicare Advantage|AARP UHC WEST COMPLETE MA|2.30||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||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|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.30||||2.30||| 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|2.30||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.30||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Aetna|AETNA 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|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.30||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Aetna|AETNA PPO|2.30||||2.30||| 85730|EAP|0305||Blue Cross HMO Specialty|BCBSTX HMO|2.30||||57.75||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Blue Cross PPO Specialty|BCBSTX PPO|2.30||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.30||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Humana Medicare Advantage|HUMANA MA|2.30||||2.30||| 85730|EAP|0305||Blue Cross PPO Specialty|BCBSTX PPO|2.30||||57.75||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Cigna|CIGNA|||||2.30||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Cigna|CIGNA|2.30||||2.30||| 85730|EAP|0305||Humana Medicare Advantage|HUMANA MA|2.30||||57.75||| 85730|EAP|0305|PTT AVTIVATED PARTIAL THR|Blue Cross PPO Specialty|BCBSTX OTHER|2.30||||2.30||| 85732|EAP|0300|LUPUS ANTICOAGULANT|Humana Medicare Advantage|HUMANA MA|||||57.75||| 85732|EAP|0305|PTT MIXING STUDY|Humana Medicare Advantage|HUMANA MA|247.75||||||| 85732|EAP|0300|LUPUS ANTICOAGULANT|Blue Cross PPO Specialty|BCBSTX PPO|||||57.75||| 85732|EAP|0300|LUPUS ANTICOAGULANT|Cigna|CIGNA|||||57.75||| 85732|EAP|0300|LUPUS ANTICOAGULANT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||57.75||| 85732|EAP|0300|LUPUS ANTICOAGULANT|Aenta Medicare Advantage|AETNA MEDICARE MA|||||57.75||| 85732|EAP|0300|LUPUS ANTICOAGULANT|Blue Cross HMO Specialty|BCBSTX HMO|||||57.75||| 85732|EAP|0300|LUPUS ANTICOAGULANT|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||57.75||| 85732|EAP|0305|PTT MIXING STUDY|United Medicare Advantage|UHC MEDICARE GOLD MA|247.75||||||| 85732|EAP|0300|LUPUS ANTICOAGULANT|United Healthcare|UNITED HEALTHCARE|||||57.75||| 85732|EAP|0305|PTT MIXING STUDY|Medicare|MEDICARE ACUTE|247.75||||||| 85732|EAP|0300|LUPUS ANTICOAGULANT|NON CONTRACTED|COMMERCIAL OTHER 1|||||57.75||| 85732|EAP|0300|LUPUS ANTICOAGULANT|Medicare|MEDICARE ACUTE|||||57.75||| 85732|EAP|0300|LUPUS ANTICOAGULANT|Managed Medicaid|MEDICAID AMERIGROUP|||||57.75||| 85732|EAP|0300|LUPUS ANTICOAGULANT|Managed Medicaid|MEDICAID SUPERIOR|247.75||||57.75||| 85732|EAP|0300|LUPUS ANTICOAGULANT|Medicaid|MEDICAID|||||57.75||| 86003|EAP|0300|FOOD ALLERGY PANEL IGE|Managed Medicaid|MEDICAID SUPERIOR|||||5.04||| 86003|EAP|0300|REGION X (TX OK) IGE PANE|Managed Medicaid|MEDICAID SUPERIOR|||||10.50||| 86003|EAP|0300|FOOD ALLERGY PANEL IGE|Managed Medicaid|MEDICAID AMERIGROUP|||||5.04||| 86003|EAP|0300|CHILDHOOD ALLERGY IGE|Managed Medicaid|MEDICAID SUPERIOR|||||285.75||| 86003|EAP|0300|REGION X (TX OK) IGE PANE|NON CONTRACTED|COMMERCIAL OTHER 1|||||10.50||| 86003|EAP|0300|REGION X (TX OK) IGE PANE|Managed Medicaid|MEDICAID AMERIGROUP|||||10.50||| 86003|EAP|0300|REGION X (TX OK) IGE PANE|Medicare|MEDICARE ACUTE|||||10.50||| 86003|EAP|0300|FOOD ALLERGY PANEL IGE|Medicare|MEDICARE ACUTE|||||5.04||| 86003|EAP|0300|REGION X (TX OK) IGE PANE|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||10.50||| 86003|EAP|0300|REGION X (TX OK) IGE PANE|United Healthcare|TML GROUP BENEFITS|||||10.50||| 86003|EAP|0300|FOOD ALLERGY PANEL IGE|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||5.04||| 86003|EAP|0300|CHILDHOOD ALLERGY IGE|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||285.75||| 86003|EAP|0300|CHILDHOOD ALLERGY IGE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||285.75||| 86003|EAP|0300|REGION X (TX OK) IGE PANE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||10.50||| 86003|EAP|0300|FOOD ALLERGY PANEL IGE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||5.04||| 86003|EAP|0300|FOOD ALLERGY PANEL IGE|Blue Cross PPO Specialty|BCBSTX PPO|||||5.04||| 86003|EAP|0300|ALLERGEN SPECIFIC IGE|Humana Medicare Advantage|HUMANA MA|||||0.42||| 86003|EAP|0300|REGION X (TX OK) IGE PANE|Blue Cross PPO Specialty|BCBSTX PPO|||||10.50||| 86003|EAP|0300|CHILDHOOD ALLERGY IGE|Blue Cross PPO Specialty|BCBSTX PPO|||||285.75||| 86022|EAP|0302|HEPRIN INDUCE THROM ANTIB|Medicare|MEDICARE ACUTE|3.75||||||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|Blue Cross PPO Specialty|BCBSTX PPO|||||1.08||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|Blue Cross PPO Specialty|BCBSTX OTHER|||||1.08||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|Cigna|CIGNA|463.25||||1.08||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1.08||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.08||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.08||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|Blue Cross HMO Specialty|BCBSTX HMO|||||1.08||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1.08||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|Veterans Affairs|VETERANS ADMINISTRATION|||||1.08||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|United Healthcare|UNITED HEALTHCARE OTHER|||||1.08||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|463.25||||1.08||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|United Healthcare|UNITED HEALTHCARE|||||1.08||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||1.08||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1.08||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|Humana Medicare Advantage|HUMANA MA|463.25||||1.08||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||1.08||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|United Medicare Advantage|UHC MEDICARE GOLD MA|463.25||||1.08||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|United Healthcare|TML GROUP BENEFITS|||||1.08||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|Medicaid|MEDICAID|463.25||||1.08||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|463.25||||1.08||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.08||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|Managed Medicare|HEALTHSPRING MA|||||1.08||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|Managed Medicaid|MEDICAID AMERIGROUP|||||1.08||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1.08||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|Managed Medicaid|MEDICAID SUPERIOR|463.25||||1.08||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|Managed Medicaid|MEDICAID UNITED HEALTHCARE|463.25||||1.08||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|Medicare|MEDICARE ACUTE|463.25||||1.08||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|Tricare|TRICARE EAST REGION|||||1.08||| 86038|EAP|0302|ANA (ANTINUCLEAR AB)|NON CONTRACTED|COMMERCIAL OTHER 1|463.25||||1.08||| 86039|EAP|0302|ANATITER (PATTERN)|NON CONTRACTED|COMMERCIAL OTHER 1|||||1.08||| 86039|EAP|0302|ANATITER (PATTERN)|Medicare|MEDICARE ACUTE|||||1.08||| 86039|EAP|0302|ANATITER (PATTERN)|Medicaid|MEDICAID|||||1.08||| 86039|EAP|0302|ANATITER (PATTERN)|Managed Medicaid|MEDICAID AMERIGROUP|||||1.08||| 86039|EAP|0302|ANATITER (PATTERN)|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1.08||| 86039|EAP|0302|ANATITER (PATTERN)|Managed Medicaid|MEDICAID SUPERIOR|463.25||||1.08||| 86039|EAP|0302|ANATITER (PATTERN)|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.08||| 86039|EAP|0302|ANATITER (PATTERN)|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1.08||| 86039|EAP|0302|ANATITER (PATTERN)|United Medicare Advantage|UHC MEDICARE GOLD MA|463.25||||1.08||| 86039|EAP|0302|ANATITER (PATTERN)|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1.08||| 86039|EAP|0302|ANATITER (PATTERN)|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1.08||| 86039|EAP|0302|ANATITER (PATTERN)|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||1.08||| 86039|EAP|0302|ANATITER (PATTERN)|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.08||| 86039|EAP|0302|ANATITER (PATTERN)|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1.08||| 86039|EAP|0302|ANATITER (PATTERN)|Blue Cross HMO Specialty|BCBSTX HMO|||||1.08||| 86039|EAP|0302|ANATITER (PATTERN)|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.08||| 86039|EAP|0302|ANATITER (PATTERN)|Humana Medicare Advantage|HUMANA MA|463.25||||1.08||| 86039|EAP|0302|ANATITER (PATTERN)|Blue Cross PPO Specialty|BCBSTX PPO|||||1.08||| 86039|EAP|0302|ANATITER (PATTERN)|Blue Cross PPO Specialty|BCBSTX OTHER|||||1.08||| 86060|EAP|0302|ASO TITER|Blue Cross PPO Specialty|BCBSTX PPO|||||65.25||| 86060|EAP|0302|ASO TITER|Blue Cross PPO Specialty|BCBSTX OTHER|||||65.25||| 86060|EAP|0302|ASO TITER|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|279.75||||||| 86060|EAP|0302|ASO TITER|Managed Medicaid|MEDICAID SUPERIOR|||||65.25||| 86060|EAP|0302|ASO TITER|Medicare|MEDICARE ACUTE|279.75||||||| 86140|EAP|0302|C-REACTIVE PROTEIN|Tricare|TRICARE EAST REGION|||||46.25||| 86140|EAP|0302|C-REACTIVE PROTEIN|NON CONTRACTED|COMMERCIAL OTHER 1|1.98||||46.25||| 86140|EAP|0302|C-REACTIVE PROTEIN|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.98||||||| 86140|EAP|0302|C-REACTIVE PROTEIN|Medicare|MEDICARE ACUTE|1.98||||46.25||| 86140|EAP|0302|C-REACTIVE PROTEIN|Rusk State Hospital|RUSK STATE HOSP|1.98||||46.25||| 86140|EAP|0302|C-REACTIVE PROTEIN|Managed Medicare|HEALTHSPRING MA|1.98||||46.25||| 86140|EAP|0302|C-REACTIVE PROTEIN|Medicaid|MEDICAID TEXAS CHILDRENS|||||46.25||| 86140|EAP|0302|C-REACTIVE PROTEIN|Medicaid|SUPERIOR HEALTHPLAN CHIP|1.98||||46.25||| 86140|EAP|0302|C-REACTIVE PROTEIN|Medicaid|MEDICAID|||||46.25||| 86140|EAP|0302|C-REACTIVE PROTEIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||46.25||| 86140|EAP|0302|C-REACTIVE PROTEIN|Managed Medicaid|MEDICAID SUPERIOR|1.98||||46.25||| 86140|EAP|0302|C-REACTIVE PROTEIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.98||||46.25||| 86140|EAP|0302|C-REACTIVE PROTEIN|Managed Medicaid|MEDICAID AMERIGROUP|||||46.25||| 86140|EAP|0302|C-REACTIVE PROTEIN|Workers Compensation|UT EMPLOYEE INJURY|1.98||||||| 86140|EAP|0302|C-REACTIVE PROTEIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.98||||46.25||| 86140|EAP|0302|C-REACTIVE PROTEIN|United Medicare Advantage|UHC MEDICARE GOLD MA|||||46.25||| 86140|EAP|0302|C-REACTIVE PROTEIN|United Medicare Advantage|AARP UHC WEST COMPLETE MA|1.98||||46.25||| 86140|EAP|0302|C-REACTIVE PROTEIN|Medicaid|MEDICAID HMO|||||46.25||| 86140|EAP|0302|C-REACTIVE PROTEIN|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||1.98||| 86140|EAP|0302|C-REACTIVE PROTEIN|Workers Compensation|WORKERS COMPENSATION OTHER|||||1.98||| 86140|EAP|0302|C-REACTIVE PROTEIN|United Healthcare|UNITED HEALTHCARE OTHER|||||46.25||| 86140|EAP|0302|C-REACTIVE PROTEIN|Aenta Medicare Advantage|AETNA MEDICARE MA|1.98||||||| 86140|EAP|0302|C-REACTIVE PROTEIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.98||||46.25||| 86140|EAP|0302|C-REACTIVE PROTEIN|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||46.25||| 86140|EAP|0302|C-REACTIVE PROTEIN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1.98||| 86140|EAP|0302|C-REACTIVE PROTEIN|Access Direct Platinum|HEALTHFIRST TPA UMR|||||46.25||| 86140|EAP|0302|C-REACTIVE PROTEIN|Blue Cross HMO Specialty|BCBSTX HMO|1.98||||46.25||| 86140|EAP|0302|C-REACTIVE PROTEIN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||46.25||| 86140|EAP|0302|C-REACTIVE PROTEIN|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.98||||1.98||| 86140|EAP|0302|C-REACTIVE PROTEIN|Brinson Benefits|THE HEALTH PLAN SMITH CO|1.98||||||| 86140|EAP|0302|C-REACTIVE PROTEIN|Humana Medicare Advantage|HUMANA MA|1.98||||46.25||| 86140|EAP|0302|C-REACTIVE PROTEIN|Blue Cross PPO Specialty|BCBSTX PPO|1.98||||46.25||| 86140|EAP|0302|C-REACTIVE PROTEIN|Blue Cross PPO Specialty|BCBSTX OTHER|1.98||||46.25||| 86140|EAP|0302|C-REACTIVE PROTEIN|Cigna|CIGNA|||||122.13||| 86141|EAP|0302|C-REACTIVE PROTEIN HIGHLY|Blue Cross PPO Specialty|BCBSTX PPO|||||115.75||| 86141|EAP|0302|C-REACTIVE PROTEIN HIGHLY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||115.75||| 86141|EAP|0302|C-REACTIVE PROTEIN HIGHLY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||496.25||| 86141|EAP|0302|C-REACTIVE PROTEIN HIGHLY|Medicaid|MEDICAID TEXAS CHILDRENS|||||115.75||| 86141|EAP|0302|C-REACTIVE PROTEIN HIGHLY|Medicaid|MEDICAID HMO|||||115.75||| 86141|EAP|0302|C-REACTIVE PROTEIN HIGHLY|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||115.75||| 86141|EAP|0302|C-REACTIVE PROTEIN HIGHLY|Managed Medicaid|MEDICAID SUPERIOR|||||115.75||| 86141|EAP|0302|C-REACTIVE PROTEIN HIGHLY|Managed Medicaid|MEDICAID AMERIGROUP|||||115.75||| 86141|EAP|0302|C-REACTIVE PROTEIN HIGHLY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||115.75||| 86141|EAP|0302|C-REACTIVE PROTEIN HIGHLY|Rusk State Hospital|RUSK STATE HOSP|||||115.75||| 86141|EAP|0302|C-REACTIVE PROTEIN HIGHLY|Medicare|MEDICARE ACUTE|||||3.06||| 86146|EAP|0300|BETA 2 GLYCOPROTEIN IGA|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.65||| 86146|EAP|0300|BETA 2 GLYCOPROTEIN IGA|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.69||| 86146|EAP|0300|BETA 2 GLYCOPROTEIN IGA|Medicare|MEDICARE ACUTE|||||0.69||| 86146|EAP|0300|BETA 2 GLYCOPROTEIN IGA|Managed Medicaid|MEDICAID SUPERIOR|2.15||||0.65||| 86146|EAP|0300|BETA 2 GLYCOPROTEIN IGA|Managed Medicaid|MEDICAID AMERIGROUP|||||0.69||| 86146|EAP|0300|BETA 2 GLYCOPROTEIN IGA|Managed Medicaid|MEDICAID SUPERIOR|2.15||||0.69||| 86146|EAP|0300|BETA 2 GLYCOPROTEIN IGA|Medicaid|MEDICAID|||||0.65||| 86146|EAP|0300|BETA 2 GLYCOPROTEIN IGA|Medicaid|MEDICAID|||||0.69||| 86146|EAP|0300|BETA 2 GLYCOPROTEIN IGA|United Healthcare|UNITED HEALTHCARE|||||0.69||| 86146|EAP|0300|BETA 2 GLYCOPROTEIN IGA|United Healthcare|UNITED HEALTHCARE|||||0.65||| 86146|EAP|0300|BETA 2 GLYCOPROTEIN IGA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.69||| 86146|EAP|0300|BETA 2 GLYCOPROTEIN IGA|Aenta Medicare Advantage|AETNA MEDICARE MA|||||0.69||| 86146|EAP|0300|BETA 2 GLYCOPROTEIN IGA|Blue Cross HMO Specialty|BCBSTX HMO|||||0.69||| 86146|EAP|0300|BETA 2 GLYCOPROTEIN IGA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.65||| 86146|EAP|0300|BETA 2 GLYCOPROTEIN IGA|Blue Cross HMO Specialty|BCBSTX HMO|||||0.65||| 86146|EAP|0300|BETA 2 GLYCOPROTEIN IGA|Blue Cross PPO Specialty|BCBSTX PPO|||||0.69||| 86146|EAP|0300|BETA 2 GLYCOPROTEIN IGA|Blue Cross PPO Specialty|BCBSTX PPO|||||0.65||| 86146|EAP|0300|BETA 2 GLYCOPROTEIN IGA|Cigna|CIGNA|||||0.65||| 86146|EAP|0300|BETA 2 GLYCOPROTEIN IGA|Humana Medicare Advantage|HUMANA MA|||||0.69||| 86146|EAP|0300|BETA 2 GLYCOPROTEIN IGA|Cigna|CIGNA|||||0.69||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGM|Humana Medicare Advantage|HUMANA MA|||||70.25||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGM|Cigna|CIGNA|3.01||||70.25||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGM|Blue Cross PPO Specialty|BCBSTX PPO|||||70.25||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGG|Cigna|CIGNA|3.01||||70.25||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGG|Blue Cross PPO Specialty|BCBSTX PPO|||||70.25||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGA|Blue Cross PPO Specialty|BCBSTX PPO|||||70.25||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGG|Humana Medicare Advantage|HUMANA MA|||||70.25||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGA|Cigna|CIGNA|3.01||||70.25||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGA|Blue Cross HMO Specialty|BCBSTX HMO|||||70.25||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGM|Aenta Medicare Advantage|AETNA MEDICARE MA|||||70.25||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||70.25||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGG|Aenta Medicare Advantage|AETNA MEDICARE MA|||||70.25||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGM|Blue Cross HMO Specialty|BCBSTX HMO|||||70.25||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||70.25||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||70.25||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGA|Aenta Medicare Advantage|AETNA MEDICARE MA|||||70.25||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGG|United Healthcare|UNITED HEALTHCARE|||||70.25||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGG|Blue Cross HMO Specialty|BCBSTX HMO|||||70.25||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGA|United Healthcare|UNITED HEALTHCARE|||||70.25||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGM|United Healthcare|UNITED HEALTHCARE|||||70.25||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGG|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||70.25||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGM|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||70.25||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGA|Managed Medicaid|MEDICAID AMERIGROUP|||||70.25||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGG|Managed Medicaid|MEDICAID SUPERIOR|3.01||||70.25||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGG|Managed Medicaid|MEDICAID AMERIGROUP|||||70.25||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGA|Managed Medicaid|MEDICAID SUPERIOR|3.01||||70.25||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGM|Managed Medicaid|MEDICAID SUPERIOR|3.01||||70.25||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGM|Managed Medicaid|MEDICAID AMERIGROUP|||||70.25||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGM|Medicaid|MEDICAID|||||70.25||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGG|Medicaid|MEDICAID|||||70.25||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGA|Medicaid|MEDICAID|||||70.25||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGG|Medicare|MEDICARE ACUTE|||||70.25||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGM|NON CONTRACTED|COMMERCIAL OTHER 1|||||70.25||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGG|NON CONTRACTED|COMMERCIAL OTHER 1|||||70.25||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGA|Medicare|MEDICARE ACUTE|||||70.25||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGM|Medicare|MEDICARE ACUTE|||||70.25||| 86147|EAP|0300|PHOSPHOLIPID ANTIBODY IGA|NON CONTRACTED|COMMERCIAL OTHER 1|||||70.25||| 86157|EAP|0305|COLD AGGLUTININS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.72||| 86157|EAP|0305|COLD AGGLUTININS|Humana Medicare Advantage|HUMANA MA|||||0.72||| 86160|EAP|0300|COMPLEMENT 3 (C3)|Medicare|MEDICARE ACUTE|||||107.25||| 86160|EAP|0302|COMPLEMENT C4|Medicare|MEDICARE ACUTE|||||107.25||| 86160|EAP|0302|COMPLEMENT C4|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||107.25||| 86160|EAP|0302|COMPLEMENT C4|Managed Medicaid|MEDICAID SUPERIOR|||||107.25||| 86160|EAP|0300|COMPLEMENT 3 (C3)|Managed Medicaid|MEDICAID AMERIGROUP|||||107.25||| 86160|EAP|0300|COMPLEMENT 3 (C3)|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||107.25||| 86160|EAP|0302|COMPLEMENT C4|Managed Medicaid|MEDICAID AMERIGROUP|||||107.25||| 86160|EAP|0300|COMPLEMENT 3 (C3)|NON CONTRACTED|COMMERCIAL OTHER 1|||||107.25||| 86160|EAP|0300|COMPLEMENT 3 (C3)|Managed Medicaid|MEDICAID SUPERIOR|||||107.25||| 86160|EAP|0302|COMPLEMENT C4|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||107.25||| 86160|EAP|0300|COMPLEMENT 3 (C3)|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||107.25||| 86160|EAP|0300|COMPLEMENT 3 (C3)|Humana Medicare Advantage|HUMANA MA|||||107.25||| 86160|EAP|0302|COMPLEMENT C4|Humana Medicare Advantage|HUMANA MA|||||107.25||| 86160|EAP|0302|COMPLEMENT C4|Blue Cross PPO Specialty|BCBSTX PPO|||||107.25||| 86160|EAP|0300|COMPLEMENT 3 (C3)|Blue Cross PPO Specialty|BCBSTX PPO|||||107.25||| 86160|EAP|0300|C1Q COMPLEMENT|Humana Medicare Advantage|HUMANA MA|||||107.25||| 86160|EAP|0302|COMPLEMENT C4|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||107.25||| 86160|EAP|0300|COMPLEMENT 3 (C3)|Blue Cross HMO Specialty|BCBSTX HMO|||||107.25||| 86160|EAP|0300|COMPLEMENT 3 (C3)|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||107.25||| 86160|EAP|0302|COMPLEMENT C4|Blue Cross HMO Specialty|BCBSTX HMO|||||107.25||| 86162|EAP|0302|COMPLEMENT TOTAL (CH50)|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||1.68||| 86162|EAP|0302|COMPLEMENT TOTAL (CH50)|United Medicare Advantage|UHC MEDICARE GOLD MA|719.75||||||| 86200|EAP|0302|CYCLIC CITRYLLINATED PEPT|Managed Medicaid|MEDICAID AMERIGROUP|||||496.25||| 86200|EAP|0302|CYCLIC CITRYLLINATED PEPT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||496.25||| 86200|EAP|0302|CYCLIC CITRYLLINATED PEPT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||496.25||| 86200|EAP|0302|CYCLIC CITRYLLINATED PEPT|NON CONTRACTED|COMMERCIAL OTHER 1|||||496.25||| 86200|EAP|0302|CYCLIC CITRYLLINATED PEPT|Medicare|MEDICARE ACUTE|||||496.25||| 86200|EAP|0302|CYCLIC CITRYLLINATED PEPT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||496.25||| 86200|EAP|0302|CYCLIC CITRYLLINATED PEPT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||496.25||| 86200|EAP|0302|CYCLIC CITRYLLINATED PEPT|Blue Cross HMO Specialty|BCBSTX HMO|||||496.25||| 86200|EAP|0302|CYCLIC CITRYLLINATED PEPT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||496.25||| 86200|EAP|0302|CYCLIC CITRYLLINATED PEPT|Blue Cross PPO Specialty|BCBSTX PPO|||||496.25||| 86200|EAP|0302|CYCLIC CITRYLLINATED PEPT|Blue Cross PPO Specialty|BCBSTX OTHER|||||496.25||| 86200|EAP|0302|CYCLIC CITRYLLINATED PEPT|Humana Medicare Advantage|HUMANA MA|||||496.25||| 86200|EAP|0302|CYCLIC CITRYLLINATED PEPT|United Medicare Advantage|UHC MEDICARE GOLD MA|496.25||||||| 86200|EAP|0302|CYCLIC CITRYLLINATED PEPT|United Healthcare|TML GROUP BENEFITS|||||496.25||| 86200|EAP|0302|CYCLIC CITRYLLINATED PEPT|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||496.25||| 86225|EAP|0302|DNA AB, DOUBLE STRANDED|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||122.75||| 86225|EAP|0302|DNA AB, DOUBLE STRANDED|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||122.75||| 86225|EAP|0302|DNA AB, DOUBLE STRANDED|Humana Medicare Advantage|HUMANA MA|||||122.75||| 86225|EAP|0302|DNA AB, DOUBLE STRANDED|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||122.75||| 86225|EAP|0302|DNA AB, DOUBLE STRANDED|Blue Cross PPO Specialty|BCBSTX PPO|||||122.75||| 86225|EAP|0302|DNA AB, DOUBLE STRANDED|Blue Cross PPO Specialty|BCBSTX OTHER|||||122.75||| 86225|EAP|0302|DNA AB, DOUBLE STRANDED|Cigna|CIGNA|||||122.75||| 86225|EAP|0302|DNA AB, DOUBLE STRANDED|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||122.75||| 86225|EAP|0302|DNA AB, DOUBLE STRANDED|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||122.75||| 86225|EAP|0302|DNA AB, DOUBLE STRANDED|Blue Cross HMO Specialty|BCBSTX HMO|||||122.75||| 86225|EAP|0302|DNA AB, DOUBLE STRANDED|NON CONTRACTED|COMMERCIAL OTHER 1|||||122.75||| 86225|EAP|0302|DNA AB, DOUBLE STRANDED|Medicare|MEDICARE ACUTE|||||122.75||| 86225|EAP|0302|DNA AB, DOUBLE STRANDED|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||122.75||| 86225|EAP|0302|DNA AB, DOUBLE STRANDED|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||122.75||| 86225|EAP|0302|DNA AB, DOUBLE STRANDED|Managed Medicaid|MEDICAID AMERIGROUP|||||122.75||| 86225|EAP|0302|DNA AB, DOUBLE STRANDED|Managed Medicaid|MEDICAID SUPERIOR|||||122.75||| 86225|EAP|0302|DNA DS ANTIBODY|Managed Medicaid|MEDICAID AMERIGROUP|||||122.75||| 86226|EAP|0302|DNA SINGLE STRANDED|Managed Medicaid|MEDICAID SUPERIOR|||||108.25||| 86226|EAP|0302|DNA SINGLE STRANDED|Managed Medicaid|MEDICAID AMERIGROUP|||||108.25||| 86226|EAP|0302|DNA SINGLE STRANDED|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||108.25||| 86226|EAP|0302|DNA SINGLE STRANDED|Blue Cross PPO Specialty|BCBSTX PPO|||||108.25||| 86235|EAP|0300|RNP ANTIBODY|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||153.75||| 86235|EAP|0302|SJOGREN'S B ANTIBODY|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||160.25||| 86235|EAP|0302|SJOGREN'S B ANTIBODY|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||160.25||| 86235|EAP|0302|SCLERODERMA ANTIBODY|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||160.25||| 86235|EAP|0300|CENTROMERE B ANTIBODY|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||1.03||| 86235|EAP|0300|SMITH-RNP ANTIBODIES|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||160.25||| 86235|EAP|0302|SJOGREN'S A ANTIBODY|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||160.25||| 86235|EAP|0302|SJOGREN'S A ANTIBODY|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||160.25||| 86235|EAP|0300|JO-1 ANTIBODY|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||160.25||| 86235|EAP|0300|RNP ANTIBODY|Humana Medicare Advantage|HUMANA MA|||||153.75||| 86235|EAP|0302|SJOGREN'S B ANTIBODY|Humana Medicare Advantage|HUMANA MA|||||160.25||| 86235|EAP|0302|SJOGREN'S A ANTIBODY|Humana Medicare Advantage|HUMANA MA|||||160.25||| 86235|EAP|0300|JO-1 ANTIBODY|Humana Medicare Advantage|HUMANA MA|||||160.25||| 86235|EAP|0302|SCLERODERMA ANTIBODY|Humana Medicare Advantage|HUMANA MA|||||160.25||| 86235|EAP|0300|SMITH ANTIBODY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||153.75||| 86235|EAP|0302|SCLERODERMA ANTIBODY|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||160.25||| 86235|EAP|0302|SJOGREN'S B ANTIBODY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||160.25||| 86235|EAP|0302|SJOGREN'S A ANTIBODY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||160.25||| 86235|EAP|0302|SCLERODERMA ANTIBODY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||160.25||| 86235|EAP|0300|RNP ANTIBODY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||153.75||| 86235|EAP|0300|JO-1 ANTIBODY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||160.25||| 86235|EAP|0302|SJOGREN'S B ANTIBODY|NON CONTRACTED|COMMERCIAL OTHER 1|||||160.25||| 86235|EAP|0300|RNP ANTIBODY|Medicare|MEDICARE ACUTE|||||153.75||| 86235|EAP|0300|RIBOSOMAL P ANTIBODY|Medicare|MEDICARE ACUTE|||||1.70||| 86235|EAP|0300|JO-1 ANTIBODY|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||160.25||| 86235|EAP|0300|JO-1 ANTIBODY|Medicare|MEDICARE ACUTE|||||160.25||| 86235|EAP|0302|SJOGREN'S B ANTIBODY|Medicare|MEDICARE ACUTE|||||160.25||| 86235|EAP|0302|SJOGREN'S A ANTIBODY|Medicare|MEDICARE ACUTE|||||160.25||| 86235|EAP|0302|SCLERODERMA ANTIBODY|Medicare|MEDICARE ACUTE|||||160.25||| 86235|EAP|0300|CENTROMERE B ANTIBODY|Medicare|MEDICARE ACUTE|||||1.03||| 86235|EAP|0302|SJOGREN'S A ANTIBODY|NON CONTRACTED|COMMERCIAL OTHER 1|||||160.25||| 86235|EAP|0302|SJOGREN'S A ANTIBODY|Managed Medicaid|MEDICAID SUPERIOR|||||160.25||| 86235|EAP|0302|SCLERODERMA ANTIBODY|Managed Medicaid|MEDICAID SUPERIOR|||||160.25||| 86235|EAP|0302|SJOGREN'S B ANTIBODY|Managed Medicaid|MEDICAID SUPERIOR|||||160.25||| 86235|EAP|0300|CENTROMERE B ANTIBODY|Managed Medicaid|MEDICAID SUPERIOR|||||1.03||| 86255|EAP|0302|SMOOTH MUSCLE ANTIBODY|Medicaid|MEDICAID|||||107.75||| 86255|EAP|0302|SMOOTH MUSCLE ANTIBODY|NON CONTRACTED|COMMERCIAL OTHER 1|||||107.75||| 86255|EAP|0302|NEUTROPHILIC CYTOPLASMIC|Medicare|MEDICARE ACUTE|107.75||||107.75||| 86255|EAP|0302|SMOOTH MUSCLE ANTIBODY|Medicare|MEDICARE ACUTE|107.75||||107.75||| 86255|EAP|0302|SMOOTH MUSCLE ANTIBODY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||107.75||| 86255|EAP|0302|NEUTROPHILIC CYTOPLASMIC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||107.75||| 86255|EAP|0302|SMOOTH MUSCLE ANTIBODY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||107.75||| 86255|EAP|0302|SMOOTH MUSCLE ANTIBODY|Blue Cross HMO Specialty|BCBSTX HMO|||||107.75||| 86255|EAP|0302|NEUTROPHILIC CYTOPLASMIC|Blue Cross HMO Specialty|BCBSTX HMO|||||107.75||| 86255|EAP|0302|NEUTROPHILIC CYTOPLASMIC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|4.62||||||| 86255|EAP|0300|PARIETAL CELL ANTIBODY|Humana Medicare Advantage|HUMANA MA|4.62||||||| 86255|EAP|0301|NEURONAL NUCLEAR(HU)ANTIB|Humana Medicare Advantage|HUMANA MA|||||233.75||| 86255|EAP|0302|SMOOTH MUSCLE ANTIBODY|Humana Medicare Advantage|HUMANA MA|4.62||||107.75||| 86255|EAP|0302|SMOOTH MUSCLE ANTIBODY|Blue Cross PPO Specialty|BCBSTX PPO|||||107.75||| 86255|EAP|0302|NEUTROPHILIC CYTOPLASMIC|Humana Medicare Advantage|HUMANA MA|4.62||||107.75||| 86255|EAP|0302|SMOOTH MUSCLE ANTIBODY|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||107.75||| 86255|EAP|0302|NEUTROPHILIC CYTOPLASMIC|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||107.75||| 86255|EAP|0302|SMOOTH MUSCLE ANTIBODY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||107.75||| 86256|EAP|0300|REFLEX TITER|Humana Medicare Advantage|HUMANA MA|||||107.75||| 86256|EAP|0300|LIVER & KIDNEY MICROSOME|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||107.75||| 86256|EAP|0300|LIVER & KIDNEY MICROSOME|Medicare|MEDICARE ACUTE|||||107.75||| 86256|EAP|0300|PARANEOPLASTIC ANTIBODIES|Medicare|MEDICARE ACUTE|||||952.50||| 86256|EAP|0300|REFLEX TITER|Managed Medicaid|MEDICAID SUPERIOR|||||452.75||| 86256|EAP|0300|LIVER & KIDNEY MICROSOME|Managed Medicaid|MEDICAID SUPERIOR|||||107.75||| 86300|EAP|0302|CA 15-3 BREAST ANTIGEN|Humana Medicare Advantage|HUMANA MA|797.25||||||| 86301|EAP|0302|CA 19-9|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1.86||| 86301|EAP|0302|CA 19-9|Managed Medicare|HEALTHSPRING MA|||||1.86||| 86301|EAP|0302|CA 19-9|Medicare|MEDICARE ACUTE|797.25||||1.86||| 86301|EAP|0302|CA 19-9|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.86||| 86301|EAP|0302|CA 19-9|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1.86||| 86301|EAP|0302|CA 19-9|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.86||| 86301|EAP|0302|CA 19-9|Humana Medicare Advantage|HUMANA MA|797.25||||1.86||| 86304|EAP|0302|CA 125|Blue Cross PPO Specialty|BCBSTX PPO|797.25||||1.86||| 86304|EAP|0302|CA 125|Humana Medicare Advantage|HUMANA MA|797.25||||1.86||| 86304|EAP|0302|CA 125|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1.86||| 86304|EAP|0302|CA 125|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.86||| 86304|EAP|0302|CA 125|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.86||| 86304|EAP|0302|CA 125|Blue Cross HMO Specialty|BCBSTX HMO|||||1.86||| 86304|EAP|0302|CA 125|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||1.86||| 86304|EAP|0302|CA 125|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.86||| 86304|EAP|0302|CA 125|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1.86||| 86304|EAP|0302|CA 125|Medicare|MEDICARE ACUTE|||||1.86||| 86304|EAP|0302|CA 125|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||491.63||| 86304|EAP|0302|CA 125|Managed Medicaid|MEDICAID AMERIGROUP|||||1.86||| 86304|EAP|0302|CA 125|Managed Medicare|HEALTHSPRING MA|||||1.86||| 86308|EAP|0302|MONONUCLEOSIS SCREENING T|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||240.88||| 86308|EAP|0302|MONONUCLEOSIS SCREENING T|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.91||| 86308|EAP|0302|MONONUCLEOSIS SCREENING T|Managed Medicaid|MEDICAID AMERIGROUP|||||0.91||| 86308|EAP|0302|MONONUCLEOSIS SCREENING T|Medicaid|MEDICAID TEXAS CHILDRENS|||||390.75||| 86308|EAP|0302|MONONUCLEOSIS SCREENING T|Medicaid|MEDICAID|||||0.91||| 86308|EAP|0302|MONONUCLEOSIS SCREENING T|Medicaid|SUPERIOR HEALTHPLAN CHIP|390.75||||||| 86308|EAP|0302|MONONUCLEOSIS SCREENING T|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.91||| 86308|EAP|0302|MONONUCLEOSIS SCREENING T|Medicare|MEDICARE ACUTE|390.75||||240.88||| 86308|EAP|0302|MONONUCLEOSIS SCREENING T|Tricare|TRICARE EAST REGION|||||0.91||| 86308|EAP|0302|MONONUCLEOSIS SCREENING T|United Healthcare|UNITED HEALTHCARE|||||0.91||| 86308|EAP|0302|MONONUCLEOSIS SCREENING T|Managed Medicaid|MEDICAID SUPERIOR|390.75||||0.91||| 86308|EAP|0302|MONONUCLEOSIS SCREENING T|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.91||| 86308|EAP|0302|MONONUCLEOSIS SCREENING T|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||390.75||| 86308|EAP|0302|MONONUCLEOSIS SCREENING T|United Healthcare|TML GROUP BENEFITS|||||0.91||| 86308|EAP|0302|MONONUCLEOSIS SCREENING T|Blue Cross HMO Specialty|BCBSTX HMO|||||0.91||| 86308|EAP|0302|MONONUCLEOSIS SCREENING T|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.91||| 86308|EAP|0302|MONONUCLEOSIS SCREENING T|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.91||| 86308|EAP|0302|MONONUCLEOSIS SCREENING T|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|390.75||||0.91||| 86308|EAP|0302|MONONUCLEOSIS SCREENING T|Blue Cross PPO Specialty|BCBSTX OTHER|||||240.88||| 86308|EAP|0302|MONONUCLEOSIS SCREENING T|Humana Medicare Advantage|HUMANA MA|||||0.91||| 86308|EAP|0302|MONONUCLEOSIS SCREENING T|Blue Cross PPO Specialty|BCBSTX PPO|||||0.91||| 86317|EAP|0300|TETANUS IGG ANTIBODY|Managed Medicaid|MEDICAID SUPERIOR|||||128.50||| 86331|EAP|0300|IMMUNOASSAY AB QUAL|Humana Medicare Advantage|HUMANA MA|||||1.03||| 86331|EAP|0300|PNEUMINITIS ANTIBODY|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||107.25||| 86332|EAP|0300|IMMUNE COMPLEX PROFILE C1|Blue Cross HMO Specialty|BCBSTX HMO|||||2.81||| 86334|EAP|0300|IMMUNOFIXATION,SERUM|Medicare|MEDICARE ACUTE|632.25||||189.25||| 86334|EAP|0300|IMMUNOFIXATION,SERUM|Humana Medicare Advantage|HUMANA MA|||||189.25||| 86334|EAP|0300|IMMUNOFIXATION,SERUM|Blue Cross PPO Specialty|BCBSTX PPO|||||189.25||| 86335|EAP|0300|URINE CONCENTRATION|Veterans Affairs|VETERANS ADMINISTRATION|||||2.40||| 86335|EAP|0300|IMMUNOFIXATION ELECT URIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||262.25||| 86335|EAP|0300|IMMUNOFIXATION ELECT URIN|United Medicare Advantage|UHC MEDICARE GOLD MA|||||262.25||| 86335|EAP|0300|IMMUNOFIXATION ELECT URIN|Veterans Affairs|VETERANS ADMINISTRATION|||||262.25||| 86335|EAP|0300|IMMUNOFIXATION ELECT URIN|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||262.25||| 86335|EAP|0300|URINE CONCENTRATION|United Healthcare|UNITED HEALTHCARE|||||2.40||| 86335|EAP|0300|IMMUNOFIXATION ELECT URIN|United Healthcare|UNITED HEALTHCARE|||||262.25||| 86335|EAP|0300|URINE CONCENTRATION|Humana Medicare Advantage|HUMANA MA|||||2.40||| 86335|EAP|0300|IMMUNOFIXATION ELECT URIN|Humana Medicare Advantage|HUMANA MA|||||262.25||| 86335|EAP|0300|URINE CONCENTRATION|Blue Cross PPO Specialty|BCBSTX PPO|||||2.40||| 86335|EAP|0300|IMMUNOFIXATION ELECT URIN|Blue Cross PPO Specialty|BCBSTX PPO|||||262.25||| 86335|EAP|0300|URINE CONCENTRATION|NON CONTRACTED|COMMERCIAL OTHER 1|||||2.40||| 86335|EAP|0300|IMMUNOFIXATION ELECT URIN|NON CONTRACTED|COMMERCIAL OTHER 1|||||262.25||| 86335|EAP|0300|URINE CONCENTRATION|Medicare|MEDICARE ACUTE|7.99||||2.40||| 86335|EAP|0300|IMMUNOFIXATION ELECT URIN|Medicare|MEDICARE ACUTE|7.99||||262.25||| 86341|EAP|0300|ISLET CELL ANTIBODY|Medicaid|MEDICAID|||||154.75||| 86341|EAP|0300|ISLET CELL ANTIBODY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||154.75||| 86341|EAP|0300|ISLET CELL ANTIBODY|Blue Cross PPO Specialty|BCBSTX PPO|||||154.75||| 86357|EAP|0300|PERCENT CD16/CD56/CD3|Managed Medicaid|MEDICAID SUPERIOR|||||3.21||| 86359|EAP|0300|PERCENT CD9|Managed Medicaid|MEDICAID SUPERIOR|||||3.21||| 86359|EAP|0300|ABSOLUTE LYMPHS|Managed Medicaid|MEDICAID SUPERIOR|||||3.21||| 86359|EAP|0300|PERCENT CD4/CD8|Managed Medicaid|MEDICAID SUPERIOR|||||3.21||| 86376|EAP|0300|THYROID PEROXIDASE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.30||| 86376|EAP|0300|THYROID PEROXIDASE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.30||| 86376|EAP|0300|THYROID PEROXIDASE|Blue Cross PPO Specialty|BCBSTX PPO|||||1.30||| 86376|EAP|0300|THYROID PEROXIDASE|Medicare|MEDICARE ACUTE|||||1.30||| 86376|EAP|0300|THYROID PEROXIDASE|Managed Medicaid|MEDICAID SUPERIOR|||||1.30||| 86376|EAP|0300|THYROID PEROXIDASE|Managed Medicaid|MEDICAID AMERIGROUP|||||1.30||| 86376|EAP|0300|THYROID PEROXIDASE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.30||| 86376|EAP|0300|THYROID PEROXIDASE|Medicaid|MEDICAID|||||1.30||| 864|DRG||FEVER AND INFLAMMATORY CONDITIONS|Medicaid|SUPERIOR HEALTHPLAN CHIP|36,325.66|3206.24|8698.55|3044.06|||| 864|DRG||FEVER AND INFLAMMATORY CONDITIONS|Medicare|MEDICARE ACUTE|25,883.50|8698.55|8698.55|3044.06|||| 864|DRG||FEVER AND INFLAMMATORY CONDITIONS|Managed Medicaid|MEDICAID SUPERIOR|18,749.08|5108.755|8698.55|3044.06|||| 864|DRG||FEVER AND INFLAMMATORY CONDITIONS|Blue Cross HMO Specialty|BCBSTX HMO|17,782.15|3044.06|8698.55|3044.06|||| 86431|EAP|0302|RA FACTOR/QUANTITIVE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|217.25||||50.75||| 86431|EAP|0302|RA FACTOR/QUANTITIVE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||50.75||| 86431|EAP|0302|RA FACTOR/QUANTITIVE|United Healthcare|TML GROUP BENEFITS|||||50.75||| 86431|EAP|0302|RA FACTOR/QUANTITIVE|United Healthcare|UNITED HEALTHCARE|||||50.75||| 86431|EAP|0302|RA FACTOR/QUANTITIVE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||50.75||| 86431|EAP|0302|RA FACTOR/QUANTITIVE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||50.75||| 86431|EAP|0302|RA FACTOR/QUANTITIVE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||50.75||| 86431|EAP|0302|RA FACTOR/QUANTITIVE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||50.75||| 86431|EAP|0302|RA FACTOR/QUANTITIVE|Blue Cross HMO Specialty|BCBSTX HMO|||||50.75||| 86431|EAP|0302|RA FACTOR/QUANTITIVE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|217.25||||50.75||| 86431|EAP|0302|RA FACTOR/QUANTITIVE|Humana Medicare Advantage|HUMANA MA|217.25||||50.75||| 86431|EAP|0302|RA FACTOR/QUANTITIVE|Veterans Affairs|VETERANS ADMINISTRATION|||||50.75||| 86431|EAP|0302|RA FACTOR/QUANTITIVE|United Medicare Advantage|UHC MEDICARE GOLD MA|217.25||||50.75||| 86431|EAP|0302|RA FACTOR/QUANTITIVE|Blue Cross PPO Specialty|BCBSTX PPO|||||50.75||| 86431|EAP|0302|RA FACTOR/QUANTITIVE|Blue Cross PPO Specialty|BCBSTX OTHER|||||50.75||| 86431|EAP|0302|RA FACTOR/QUANTITIVE|Tricare|TRICARE EAST REGION|||||50.75||| 86431|EAP|0302|RA FACTOR/QUANTITIVE|NON CONTRACTED|COMMERCIAL OTHER 1|217.25||||50.75||| 86431|EAP|0302|RA FACTOR/QUANTITIVE|Medicare|MEDICARE ACUTE|217.25||||50.75||| 86431|EAP|0302|RA FACTOR/QUANTITIVE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|217.25||||50.75||| 86431|EAP|0302|RA FACTOR/QUANTITIVE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||50.75||| 86431|EAP|0302|RA FACTOR/QUANTITIVE|Managed Medicaid|MEDICAID AMERIGROUP|||||50.75||| 86431|EAP|0302|RA FACTOR/QUANTITIVE|Managed Medicaid|MEDICAID SUPERIOR|217.25||||50.75||| 86431|EAP|0302|RA FACTOR/QUANTITIVE|Managed Medicare|HEALTHSPRING MA|||||50.75||| 86431|EAP|0302|RA FACTOR/QUANTITIVE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||50.75||| 86431|EAP|0302|RA FACTOR/QUANTITIVE|Medicaid|MEDICAID|||||50.75||| 86480|EAP|0300|QUANTIFERON TB GOLD|Managed Medicaid|MEDICAID SUPERIOR|||||5.44||| 86480|EAP|0300|QUANTIFERON TB GOLD|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||5.44||| 86480|EAP|0300|QUANTIFERON TB GOLD|Blue Cross HMO Specialty|BCBSTX HMO|||||5.44||| 86480|EAP|0300|QUANTIFERON TB GOLD|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||5.44||| 86480|EAP|0300|QUANTIFERON TB GOLD|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,331.25||| 86580|EAP|0302|TB SKIN TEST|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||34.50||| 86580|EAP|0302|TB SKIN TEST|United Healthcare|UNITED HEALTHCARE|||||34.50||| 86580|EAP|0302|TB SKIN TEST|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||34.50||| 86580|EAP|0302|TB SKIN TEST|Blue Cross PPO Specialty|BCBSTX PPO|||||34.50||| 86580|EAP|0302|TB SKIN TEST|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||34.50||| 86580|EAP|0302|TB SKIN TEST|Managed Medicaid|MEDICAID SUPERIOR|||||34.50||| 86592|EAP|0300|RPR|NON CONTRACTED|COMMERCIAL OTHER 2|||||38.25||| 86592|EAP|0300|RPR|Tricare|TRICARE EAST REGION|163.25||||38.25||| 86592|EAP|0300|RPR|Medicare|MEDICARE ACUTE|||||38.25||| 86592|EAP|0300|RPR|Rusk State Hospital|RUSK STATE HOSP|||||38.25||| 86592|EAP|0302|VDRL CSF|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||38.25||| 86592|EAP|0300|RPR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|163.25||||38.25||| 86592|EAP|0300|RPR|Managed Medicaid|MEDICAID SUPERIOR|163.25||||38.25||| 86592|EAP|0300|RPR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||38.25||| 86592|EAP|0300|RPR|Medicaid|MOLINA HEALTHCARE OF TEXAS|163.25||||38.25||| 86592|EAP|0300|RPR|Medicaid|MEDICAID|163.25||||38.25||| 86592|EAP|0300|RPR|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||38.25||| 86592|EAP|0300|RPR|Managed Medicaid|MEDICAID AMERIGROUP|163.25||||38.25||| 86592|EAP|0300|RPR|Medicaid|MEDICAID HMO|||||38.25||| 86592|EAP|0300|RPR|Cigna|CIGNA|163.25||||38.25||| 86592|EAP|0300|RPR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|163.25||||38.25||| 86592|EAP|0300|RPR|Humana Medicare Advantage|HUMANA MA|||||38.25||| 86592|EAP|0300|RPR|Blue Cross PPO Specialty|BCBSTX PPO|163.25||||38.25||| 86592|EAP|0300|RPR|Blue Cross PPO Specialty|BCBSTX OTHER|||||38.25||| 86592|EAP|0300|RPR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|163.25||||38.25||| 86592|EAP|0300|RPR|Aetna|AETNA OTHER|||||38.25||| 86592|EAP|0300|RPR|Access Direct Platinum|HEALTHFIRST TPA UMR|||||38.25||| 86592|EAP|0300|RPR|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|163.25||||38.25||| 86592|EAP|0300|RPR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|163.25||||38.25||| 86592|EAP|0300|RPR|Blue Cross HMO Specialty|BCBSTX HMO|163.25||||38.25||| 86592|EAP|0300|RPR|NON CONTRACTED|COMMERCIAL OTHER 1|163.25||||38.25||| 86592|EAP|0300|RPR|Aetna|AETNA PPO|||||38.25||| 86592|EAP|0300|RPR|Aenta Medicare Advantage|AETNA MEDICARE MA|||||38.25||| 86592|EAP|0300|RPR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||38.25||| 86592|EAP|0300|RPR|United Medicare Advantage|UHC MEDICARE GOLD MA|||||38.25||| 86592|EAP|0300|RPR|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||38.25||| 86592|EAP|0300|RPR|United Healthcare|UNITED HEALTHCARE|163.25||||38.25||| 86592|EAP|0300|RPR|United Healthcare|UNITED HEALTHCARE OTHER|163.25||||38.25||| 86592|EAP|0300|RPR|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||38.25||| 866|DRG||VIRAL ILLNESS W/O MCC|Managed Medicaid|MEDICAID SUPERIOR|22,515.90|5497.14|8503.02|5497.14|||| 866|DRG||VIRAL ILLNESS W/O MCC|Medicare|MEDICARE ACUTE|14,363.15|8503.02|8503.02|5497.14|||| 86606|EAP|0300|PNEUMONIA PANEL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||0.73||| 86611|EAP|0300|BARTONELLA HENSELAE IGM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.73||| 86611|EAP|0300|BARTONELLA HENSELAE IGM|Managed Medicaid|MEDICAID AMERIGROUP|||||0.73||| 86611|EAP|0300|BARTONELLA HENSELAE IGG|Managed Medicaid|MEDICAID AMERIGROUP|||||0.73||| 86611|EAP|0300|BARTONELLA HENSELAE IGG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.73||| 86611|EAP|0300|BARTONELLA HENSELAE IGM|Managed Medicaid|MEDICAID SUPERIOR|||||0.73||| 86611|EAP|0300|BARTONELLA HENSELAE IGG|Managed Medicaid|MEDICAID SUPERIOR|||||0.73||| 86611|EAP|0300|BARTONELLA HENSELAE IGG|Medicaid|SUPERIOR HEALTHPLAN CHIP|313.50||||0.73||| 86611|EAP|0300|BARTONELLA HENSELAE IGM|Medicaid|SUPERIOR HEALTHPLAN CHIP|313.50||||0.73||| 86611|EAP|0300|BARTONELLA HENSELAE IGG|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.73||| 86611|EAP|0300|BARTONELLA HENSELAE IGM|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.73||| 86611|EAP|0300|BARTONELLA HENSELAE IGG|Medicare|MEDICARE ACUTE|||||0.73||| 86611|EAP|0300|BARTONELLA HENSELAE IGM|Medicare|MEDICARE ACUTE|||||0.73||| 86611|EAP|0300|BARTONELLA HENSELAE IGM|Access Direct Platinum|HEALTHFIRST TPA UMR|||||0.73||| 86611|EAP|0300|BARTONELLA HENSELAE IGG|Access Direct Platinum|HEALTHFIRST TPA UMR|||||0.73||| 86611|EAP|0300|BARTONELLA HENSELAE IGM|Humana Medicare Advantage|HUMANA MA|||||0.73||| 86611|EAP|0300|BARTONELLA HENSELAE IGM|Blue Cross PPO Specialty|BCBSTX PPO|||||0.73||| 86611|EAP|0300|BARTONELLA HENSELAE IGG|Blue Cross PPO Specialty|BCBSTX PPO|||||0.73||| 86611|EAP|0300|BARTONELLA HENSELAE IGG|Humana Medicare Advantage|HUMANA MA|||||0.73||| 86617|EAP|0300|LYME DISEASE WESTERN BLOT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.33||| 86617|EAP|0300|LYMES DISEASE WESTERN BLO|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.33||| 86618|EAP|0302|LYME'S DISEASE ANTIBODY T|Medicare|MEDICARE ACUTE|||||152.25||| 86618|EAP|0302|LYME'S DISEASE ANTIBODY T|Medicaid|MEDICAID|||||152.25||| 86618|EAP|0302|LYME'S DISEASE ANTIBODY T|United Medicare Advantage|UHC MEDICARE GOLD MA|||||152.25||| 86618|EAP|0302|LYME'S DISEASE ANTIBODY T|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||152.25||| 86618|EAP|0302|LYME'S DISEASE ANTIBODY T|Blue Cross PPO Specialty|BCBSTX PPO|||||152.25||| 86618|EAP|0302|LYME'S DISEASE ANTIBODY T|Humana Medicare Advantage|HUMANA MA|||||152.25||| 86618|EAP|0302|LYME'S DISEASE ANTIBODY T|Cigna|CIGNA|||||152.25||| 86618|EAP|0302|LYME'S DISEASE ANTIBODY T|Blue Cross HMO Specialty|BCBSTX HMO|||||152.25||| 86618|EAP|0302|LYME'S DISEASE ANTIBODY T|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||152.25||| 86622|EAP|0302|BRUCELLA ABORTUS ANTIBODY|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.67||| 86622|EAP|0302|BRUCELLA ABORTUS ANTIBODY|Medicare|MEDICARE ACUTE|||||0.67||| 86635|EAP|0300|COCCIDIOIDES|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||71.75||| 86635|EAP|0300|COCCIDIOIDES|United Medicare Advantage|UHC MEDICARE GOLD MA|||||71.75||| 86644|EAP|0302|CYTOMEGALOVIRUS IGG & IGM|Managed Medicaid|MEDICAID SUPERIOR|||||0.73||| 86644|EAP|0300|CYTOMEGALOVIRUS IGG|Managed Medicaid|MEDICAID SUPERIOR|551.50||||||| 86644|EAP|0300|CYTOMEGALOVIRUS IGG|Managed Medicaid|MEDICAID AMERIGROUP|||||128.75||| 86644|EAP|0302|CYTOMEGALOVIRUS IGG & IGM|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.73||| 86644|EAP|0302|CYTOMEGALOVIRUS IGG & IGM|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||0.73||| 86644|EAP|0302|CYTOMEGALOVIRUS IGG & IGM|Blue Cross PPO Specialty|BCBSTX PPO|||||0.73||| 86644|EAP|0300|CYTOMEGALOVIRUS IGG|Blue Cross HMO Specialty|BCBSTX HMO|||||128.75||| 86645|EAP|0300|CYTOMEGALOVIRUS IGM ANTIB|Blue Cross HMO Specialty|BCBSTX HMO|||||0.73||| 86645|EAP|0300|CYTOMEGALOVIRUS IGM ANTIB|Managed Medicaid|MEDICAID AMERIGROUP|||||0.73||| 86645|EAP|0300|CYTOMEGALOVIRUS IGM ANTIB|Managed Medicaid|MEDICAID SUPERIOR|313.50||||||| 86663|EAP|0300|EPSTEIN BARR,EARLY ANTIGE|NON CONTRACTED|COMMERCIAL OTHER 1|||||211.75||| 86663|EAP|0300|EPSTEIN BARR,EARLY ANTIGE|Managed Medicaid|MEDICAID AMERIGROUP|||||211.75||| 86663|EAP|0300|EPSTEIN BARR,EARLY ANTIGE|Managed Medicaid|MEDICAID SUPERIOR|||||211.75||| 86663|EAP|0300|EPSTEIN BARR,EARLY ANTIGE|Medicaid|SUPERIOR HEALTHPLAN CHIP|211.75||||||| 86663|EAP|0300|EPSTEIN BARR,EARLY ANTIGE|Blue Cross PPO Specialty|BCBSTX PPO|||||211.75||| 86663|EAP|0300|EPSTEIN BARR,EARLY ANTIGE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||211.75||| 86664|EAP|0302|EBV NUCLEAR ANTIGEN AB IG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||136.75||| 86664|EAP|0302|EBV NUCLEAR ANTIGEN AB IG|Blue Cross PPO Specialty|BCBSTX PPO|||||136.75||| 86664|EAP|0302|EBV NUCLEAR ANTIGEN AB IG|Managed Medicaid|MEDICAID SUPERIOR|||||136.75||| 86664|EAP|0302|EBV NUCLEAR ANTIGEN AB IG|Managed Medicaid|MEDICAID AMERIGROUP|||||136.75||| 86664|EAP|0302|EBV NUCLEAR ANTIGEN AB IG|NON CONTRACTED|COMMERCIAL OTHER 1|||||136.75||| 86665|EAP|0302|EPSTEIN BARR VIRUS IGG AB|NON CONTRACTED|COMMERCIAL OTHER 1|||||1.62||| 86665|EAP|0302|EPSTEIN BARR VIRUS IG M|NON CONTRACTED|COMMERCIAL OTHER 1|||||1.62||| 86665|EAP|0302|EPSTEIN BARR VIRUS IGG AB|Managed Medicaid|MEDICAID SUPERIOR|||||1.62||| 86665|EAP|0302|EPSTEIN BARR VIRUS IG M|Managed Medicaid|MEDICAID SUPERIOR|||||1.62||| 86665|EAP|0302|EPSTEIN BARR VIRUS IG M|Managed Medicaid|MEDICAID AMERIGROUP|||||1.62||| 86665|EAP|0302|EB VIRUS NUCLEAR ANTIGEN|Managed Medicaid|MEDICAID SUPERIOR|||||136.75||| 86665|EAP|0302|EPSTEIN BARR VIRUS IGG AB|Managed Medicaid|MEDICAID AMERIGROUP|||||1.62||| 86665|EAP|0302|EPSTEIN BARR VIRUS IG M|Medicaid|SUPERIOR HEALTHPLAN CHIP|6.95||||||| 86665|EAP|0302|EPSTEIN BARR VIRUS IGG AB|Medicaid|SUPERIOR HEALTHPLAN CHIP|502.25||||||| 86665|EAP|0302|EB VIRUS NUCLEAR ANTIGEN|Medicaid|SUPERIOR HEALTHPLAN CHIP|574.75||||||| 86665|EAP|0302|EPSTEIN BARR VIRUS IGG AB|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.62||| 86665|EAP|0302|EPSTEIN BARR VIRUS IG M|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||1.62||| 86665|EAP|0302|EPSTEIN BARR VIRUS IGG AB|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||1.62||| 86665|EAP|0302|EPSTEIN BARR VIRUS IG M|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.62||| 86665|EAP|0302|EPSTEIN BARR VIRUS IGG AB|Blue Cross PPO Specialty|BCBSTX PPO|||||1.62||| 86665|EAP|0302|EPSTEIN BARR VIRUS IG M|Blue Cross PPO Specialty|BCBSTX PPO|||||1.62||| 86665|EAP|0302|EPSTEIN BARR VIRUS IGG AB|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.62||| 86665|EAP|0302|EPSTEIN BARR VIRUS IG M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.62||| 86665|EAP|0302|EPSTEIN BARR VIRUS IG M|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|6.95||||||| 86665|EAP|0302|EPSTEIN BARR VIRUS IGG AB|Blue Cross HMO Specialty|BCBSTX HMO|||||1.62||| 86665|EAP|0302|EPSTEIN BARR VIRUS IG M|Blue Cross HMO Specialty|BCBSTX HMO|||||1.62||| 86668|EAP|0302|TULAREMIA SCREEN|Medicaid|SUPERIOR HEALTHPLAN CHIP|398.50||||||| 86671|EAP|0300|ANTIBODY,FUNGUS|Humana Medicare Advantage|HUMANA MA|313.50||||0.73||| 86671|EAP|0300|SACCHAROMYCES CEREVISIAE|Blue Cross PPO Specialty|BCBSTX PPO|||||0.67||| 86671|EAP|0300|SACCHAROMYCES CEREVISIAE|United Healthcare|UNITED HEALTHCARE OTHER|||||0.67||| 86671|EAP|0300|SACCHAROMYCES CEREVISIAE|Medicare|MEDICARE ACUTE|||||0.67||| 86671|EAP|0300|SACCHAROMYCES CEREVISIAE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.67||| 86684|EAP|0302|H INFLUENZA AB|Managed Medicaid|MEDICAID SUPERIOR|||||606.75||| 86694|EAP|0302|HERPES SIMPLEX NON-SPECF|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||128.75||| 86694|EAP|0302|HERPES SIMPLEX NON-SPECF|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||128.75||| 86694|EAP|0302|HERPES SIMPLEX NON-SPECF|Blue Cross HMO Specialty|BCBSTX HMO|||||128.75||| 86694|EAP|0302|HERPES SIMPLEX NON-SPECF|Humana Medicare Advantage|HUMANA MA|||||128.75||| 86694|EAP|0302|HERPES SIMPLEX NON-SPECF|NON CONTRACTED|COMMERCIAL OTHER 1|||||128.75||| 86694|EAP|0302|HERPES SIMPLEX NON-SPECF|Medicare|MEDICARE ACUTE|||||128.75||| 86694|EAP|0302|HERPES SIMPLEX NON-SPECF|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||128.75||| 86694|EAP|0302|HERPES SIMPLEX NON-SPECF|Managed Medicaid|MEDICAID AMERIGROUP|||||128.75||| 86694|EAP|0302|HERPES SIMPLEX NON-SPECF|Managed Medicaid|MEDICAID SUPERIOR|551.50||||128.75||| 86694|EAP|0302|HERPES SIMPLEX NON-SPECF|Medicaid|MEDICAID|||||340.13||| 86695|EAP|0300|HERPES SIMPLEX TYPE I|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||117.75||| 86695|EAP|0300|HERPES SIMPLEX TYPE I|Medicaid|MEDICAID|||||311.50||| 86695|EAP|0300|HERPES SIMPLEX TYPE I|Managed Medicaid|MEDICAID AMERIGROUP|||||117.75||| 86695|EAP|0300|HERPES SIMPLEX TYPE I|Managed Medicaid|MEDICAID SUPERIOR|505.25||||117.75||| 86695|EAP|0300|HERPES SIMPLEX TYPE I|NON CONTRACTED|COMMERCIAL OTHER 1|||||117.75||| 86695|EAP|0300|HERPES SIMPLEX TYPE I|Medicare|MEDICARE ACUTE|||||117.75||| 86695|EAP|0300|HERPES SIMPLEX TYPE I|Humana Medicare Advantage|HUMANA MA|||||117.75||| 86695|EAP|0300|HERPES SIMPLEX TYPE I|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||117.75||| 86695|EAP|0300|HERPES SIMPLEX TYPE I|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||117.75||| 86695|EAP|0300|HERPES SIMPLEX TYPE I|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||117.75||| 86695|EAP|0300|HERPES SIMPLEX TYPE I|Blue Cross HMO Specialty|BCBSTX HMO|||||117.75||| 86695|EAP|0300|HERPES SIMPLEX TYPE I|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||117.75||| 86695|EAP|0300|HERPES SIMPLEX TYPE I|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||117.75||| 86696|EAP|0302|HERPES SIMPLEX TYPE II|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||1.73||| 86696|EAP|0302|HERPES SIMPLEX TYPE II|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1.73||| 86696|EAP|0302|HERPES SIMPLEX TYPE II|Blue Cross HMO Specialty|BCBSTX HMO|||||1.73||| 86696|EAP|0302|HERPES SIMPLEX TYPE II|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.73||| 86696|EAP|0302|HERPES SIMPLEX TYPE II|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.73||| 86696|EAP|0302|HERPES SIMPLEX TYPE II|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1.73||| 86696|EAP|0302|HERPES SIMPLEX TYPE II|Humana Medicare Advantage|HUMANA MA|||||1.73||| 86696|EAP|0302|HERPES SIMPLEX TYPE II|Medicare|MEDICARE ACUTE|||||1.73||| 86696|EAP|0302|HERPES SIMPLEX TYPE II|NON CONTRACTED|COMMERCIAL OTHER 1|||||1.73||| 86696|EAP|0302|HERPES SIMPLEX TYPE II|Managed Medicaid|MEDICAID AMERIGROUP|||||1.73||| 86696|EAP|0302|HERPES SIMPLEX TYPE II|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1.73||| 86696|EAP|0302|HERPES SIMPLEX TYPE II|Managed Medicaid|MEDICAID SUPERIOR|741.50||||1.73||| 86696|EAP|0302|HERPES SIMPLEX TYPE II|Medicaid|MEDICAID|||||457.25||| 86701|EAP|0300|HIV 1 ANTIBODY|Managed Medicaid|MEDICAID SUPERIOR|||||0.66||| 86702|EAP|0300|HIV 2 ANTIBODY|Managed Medicaid|MEDICAID SUPERIOR|||||1.00||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|525.50||||122.50||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Humana Medicare Advantage|HUMANA MA|525.50||||122.50||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Cigna|CIGNA|525.50||||122.50||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Blue Cross PPO Specialty|BCBSTX PPO|525.50||||122.50||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Blue Cross PPO Specialty|BCBSTX OTHER|||||122.50||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Aetna|AETNA PPO|||||122.50||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|525.50||||122.50||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|525.50||||122.50||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Access Direct Platinum|HEALTHFIRST TPA UMR|||||122.50||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Blue Cross HMO Specialty|BCBSTX HMO|525.50||||122.50||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|United Medicare Advantage|UHC MEDICARE GOLD MA|||||122.50||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||122.50||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||122.50||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Aenta Medicare Advantage|AETNA MEDICARE MA|||||122.50||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|United Healthcare|UNITED HEALTHCARE|525.50||||122.50||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|United Healthcare|UNITED HEALTHCARE OTHER|525.50||||122.50||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|525.50||||122.50||| 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|AARP UHC WEST COMPLETE MA|||||122.50||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Workers Compensation|UT EMPLOYEE INJURY|||||525.50||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|United Healthcare|UNITED HEALTHCARE|||||122.50||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|United Healthcare|TML GROUP BENEFITS|||||122.50||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|NON CONTRACTED|COMMERCIAL OTHER 2|||||122.50||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|NON CONTRACTED|COMMERCIAL OTHER 1|525.50||||122.50||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Rusk State Hospital|RUSK STATE HOSP|||||122.50||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Medicare|MEDICARE ACUTE|||||122.50||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Tricare|TRICARE EAST REGION|525.50||||122.50||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Managed Medicaid|MEDICAID SUPERIOR|525.50||||122.50||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Managed Medicaid|MEDICAID AMERIGROUP|525.50||||122.50||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|525.50||||122.50||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|525.50||||122.50||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Medicaid|MEDICAID|525.50||||122.50||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||122.50||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Medicaid|MOLINA HEALTHCARE OF TEXAS|525.50||||122.50||| 86703|EAP|0302|HIV 1/2 ANTIBODY SCREEN|Medicaid|MEDICAID HMO|||||122.50||| 86704|EAP|0300|HEPATITIS B CORE ANTIBODY|Managed Medicare|HEALTHSPRING MA|||||107.75||| 86704|EAP|0300|HEPATITIS B CORE ANTIBODY|Managed Medicaid|MEDICAID SUPERIOR|||||107.75||| 86704|EAP|0300|HEPATITIS B CORE ANTIBODY|Managed Medicaid|MEDICAID AMERIGROUP|4.62||||107.75||| 86704|EAP|0300|HEPATITIS B CORE ANTIBODY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||107.75||| 86704|EAP|0300|HEPATITIS B CORE ANTIBODY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||107.75||| 86704|EAP|0300|HEPATITIS B CORE ANTIBODY|Medicaid|MEDICAID|4.62||||107.75||| 86704|EAP|0300|HEPATITIS B CORE ANTIBODY|NON CONTRACTED|COMMERCIAL OTHER 1|||||107.75||| 86704|EAP|0300|HEPATITIS B CORE ANTIBODY|Medicare|MEDICARE ACUTE|107.75||||107.75||| 86704|EAP|0300|HEPATITIS B CORE ANTIBODY|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||107.75||| 86704|EAP|0300|HEPATITIS B CORE ANTIBODY|United Medicare Advantage|UHC MEDICARE GOLD MA|||||107.75||| 86704|EAP|0300|HEPATITIS B CORE ANTIBODY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||107.75||| 86704|EAP|0300|HEPATITIS B CORE ANTIBODY|Workers Compensation|UT EMPLOYEE INJURY|||||4.62||| 86704|EAP|0300|HEPATITIS B CORE ANTIBODY|United Healthcare|UNITED HEALTHCARE|||||107.75||| 86704|EAP|0300|HEPATITIS B CORE ANTIBODY|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||107.75||| 86704|EAP|0300|HEPATITIS B CORE ANTIBODY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||107.75||| 86704|EAP|0300|HEPATITIS B CORE ANTIBODY|Managed Medicare|BCBS MEDICARE PPO MA|||||107.75||| 86704|EAP|0300|HEPATITIS B CORE ANTIBODY|United Healthcare|TML GROUP BENEFITS|||||107.75||| 86704|EAP|0300|HEPATITIS B CORE ANTIBODY|Aenta Medicare Advantage|AETNA MEDICARE MA|||||107.75||| 86704|EAP|0300|HEPATITIS B CORE ANTIBODY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||107.75||| 86704|EAP|0300|HEPATITIS B CORE ANTIBODY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||107.75||| 86704|EAP|0300|HEPATITIS B CORE ANTIBODY|Access Direct Platinum|HEALTHFIRST TPA UMR|||||107.75||| 86704|EAP|0300|HEPATITIS B CORE ANTIBODY|Blue Cross HMO Specialty|BCBSTX HMO|||||107.75||| 86704|EAP|0300|HEPATITIS B CORE ANTIBODY|Blue Cross PPO Specialty|BCBSTX PPO|||||107.75||| 86704|EAP|0300|HEPATITIS B CORE ANTIBODY|Humana Medicare Advantage|HUMANA MA|||||107.75||| 86704|EAP|0300|HEPATITIS B CORE ANTIBODY|Blue Cross PPO Specialty|BCBSTX OTHER|||||107.75||| 86705|EAP|0302|HEPATITIS B CORE ANTIBODY|Humana Medicare Advantage|HUMANA MA|450.75||||105.25||| 86705|EAP|0302|HEPATITIS B CORE ANTIBODY|Blue Cross PPO Specialty|BCBSTX PPO|||||105.25||| 86705|EAP|0300|HEPATITIS B CORE IGM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||105.25||| 86705|EAP|0302|HEPATITIS B CORE ANTIBODY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||105.25||| 86705|EAP|0302|HEPATITIS B CORE ANTIBODY|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||105.25||| 86705|EAP|0302|HEPATITIS B CORE ANTIBODY|Access Direct Platinum|HEALTHFIRST TPA UMR|||||105.25||| 86705|EAP|0302|HEPATITIS B CORE ANTIBODY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||105.25||| 86705|EAP|0302|HEPATITIS B CORE ANTIBODY|Aenta Medicare Advantage|AETNA MEDICARE MA|||||105.25||| 86705|EAP|0302|HEPATITIS B CORE ANTIBODY|United Medicare Advantage|UHC MEDICARE GOLD MA|||||105.25||| 86705|EAP|0302|HEPATITIS B CORE ANTIBODY|United Healthcare|UNITED HEALTHCARE|||||105.25||| 86705|EAP|0302|HEPATITIS B CORE ANTIBODY|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||105.25||| 86705|EAP|0302|HEPATITIS B CORE ANTIBODY|United Healthcare|TML GROUP BENEFITS|||||105.25||| 86705|EAP|0302|HEPATITIS B CORE ANTIBODY|Blue Cross HMO Specialty|BCBSTX HMO|||||105.25||| 86705|EAP|0302|HEPATITIS B CORE ANTIBODY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||105.25||| 86705|EAP|0302|HEPATITIS B CORE ANTIBODY|United Medicare Advantage|AARP UHC WEST COMPLETE MA|450.75||||105.25||| 86705|EAP|0302|HEPATITIS B CORE ANTIBODY|Blue Cross PPO Specialty|BCBSTX OTHER|||||105.25||| 86705|EAP|0302|HEPATITIS B CORE ANTIBODY|Workers Compensation|WORKERS COMPENSATION OTHER|||||450.75||| 86705|EAP|0302|HEPATITIS B CORE ANTIBODY|NON CONTRACTED|COMMERCIAL OTHER 1|||||105.25||| 86705|EAP|0302|HEPATITIS B CORE ANTIBODY|Rusk State Hospital|RUSK STATE HOSP|||||105.25||| 86705|EAP|0302|HEPATITIS B CORE ANTIBODY|Medicare|MEDICARE ACUTE|105.25||||105.25||| 86705|EAP|0302|HEPATITIS B CORE ANTIBODY|Managed Medicaid|MEDICAID SUPERIOR|||||105.25||| 86705|EAP|0302|HEPATITIS B CORE ANTIBODY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||105.25||| 86705|EAP|0302|HEPATITIS B CORE ANTIBODY|Managed Medicaid|MEDICAID AMERIGROUP|450.75||||105.25||| 86705|EAP|0302|HEPATITIS B CORE ANTIBODY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||105.25||| 86705|EAP|0302|HEPATITIS B CORE ANTIBODY|Medicaid|MEDICAID|||||105.25||| 86705|EAP|0302|HEPATITIS B CORE ANTIBODY|Managed Medicare|HEALTHSPRING MA|||||105.25||| 86705|EAP|0302|HEPATITIS B CORE ANTIBODY|Managed Medicare|BCBS MEDICARE PPO MA|||||105.25||| 86705|EAP|0302|HEPATITIS B CORE ANTIBODY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||105.25||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|Managed Medicaid|MEDICAID SUPERIOR|||||0.96||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.96||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|Managed Medicaid|MEDICAID AMERIGROUP|411.50||||0.96||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.96||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.96||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|Managed Medicare|BCBS MEDICARE PPO MA|||||0.96||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|Managed Medicare|HEALTHSPRING MA|||||0.96||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|Medicaid|MEDICAID|411.50||||0.96||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.96||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|Medicare|MEDICARE ACUTE|0.96||||0.96||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|Tricare|TRICARE FOR LIFE|||||0.96||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|United Healthcare|UNITED HEALTHCARE|||||0.96||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||0.96||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|United Healthcare|TML GROUP BENEFITS|||||0.96||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.96||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|United Medicare Advantage|AARP UHC WEST COMPLETE MA|411.50||||0.96||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.96||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|Workers Compensation|WORKERS COMPENSATION OTHER|||||411.50||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|Workers Compensation|UT EMPLOYEE INJURY|||||411.50||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|Aenta Medicare Advantage|AETNA MEDICARE MA|||||0.96||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.96||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.96||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.96||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|Access Direct Platinum|HEALTHFIRST TPA UMR|||||0.96||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|Blue Cross HMO Specialty|BCBSTX HMO|||||0.96||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.96||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|Humana Medicare Advantage|HUMANA MA|||||0.96||| 86706|EAP|0302|HEPATITIS B SURFACE ANTIB|Blue Cross PPO Specialty|BCBSTX PPO|||||0.96||| 86707|EAP|0302|HEPATITIS BE ANTIBODY|Humana Medicare Advantage|HUMANA MA|||||103.50||| 86707|EAP|0302|HEPATITIS BE ANTIBODY|Blue Cross PPO Specialty|BCBSTX OTHER|||||103.50||| 86707|EAP|0302|HEPATITIS BE ANTIBODY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||103.50||| 86707|EAP|0302|HEPATITIS BE ANTIBODY|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||103.50||| 86707|EAP|0302|HEPATITIS BE ANTIBODY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||103.50||| 86707|EAP|0302|HEPATITIS BE ANTIBODY|Aenta Medicare Advantage|AETNA MEDICARE MA|||||103.50||| 86707|EAP|0302|HEPATITIS BE ANTIBODY|Blue Cross HMO Specialty|BCBSTX HMO|||||103.50||| 86707|EAP|0302|HEPATITIS BE ANTIBODY|Access Direct Platinum|HEALTHFIRST TPA UMR|||||103.50||| 86707|EAP|0302|HEPATITIS BE ANTIBODY|United Healthcare|TML GROUP BENEFITS|||||103.50||| 86707|EAP|0302|HEPATITIS BE ANTIBODY|United Medicare Advantage|UHC MEDICARE GOLD MA|||||103.50||| 86707|EAP|0302|HEPATITIS BE ANTIBODY|United Healthcare|UNITED HEALTHCARE|||||103.50||| 86707|EAP|0302|HEPATITIS BE ANTIBODY|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||103.50||| 86707|EAP|0302|HEPATITIS BE ANTIBODY|Blue Cross PPO Specialty|BCBSTX PPO|||||103.50||| 86707|EAP|0302|HEPATITIS BE ANTIBODY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||103.50||| 86707|EAP|0302|HEPATITIS BE ANTIBODY|United Medicare Advantage|AARP UHC WEST COMPLETE MA|443.25||||103.50||| 86707|EAP|0302|HEPATITIS BE ANTIBODY|Medicare|MEDICARE ACUTE|103.50||||103.50||| 86707|EAP|0302|HEPATITIS BE ANTIBODY|NON CONTRACTED|COMMERCIAL OTHER 1|||||103.50||| 86707|EAP|0302|HEPATITIS BE ANTIBODY|Managed Medicaid|MEDICAID SUPERIOR|||||103.50||| 86707|EAP|0302|HEPATITIS BE ANTIBODY|Managed Medicaid|MEDICAID AMERIGROUP|443.25||||103.50||| 86707|EAP|0302|HEPATITIS BE ANTIBODY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||103.50||| 86707|EAP|0302|HEPATITIS BE ANTIBODY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||103.50||| 86707|EAP|0302|HEPATITIS BE ANTIBODY|Managed Medicare|BCBS MEDICARE PPO MA|||||103.50||| 86707|EAP|0302|HEPATITIS BE ANTIBODY|Managed Medicare|HEALTHSPRING MA|||||103.50||| 86707|EAP|0302|HEPATITIS BE ANTIBODY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||103.50||| 86707|EAP|0302|HEPATITIS BE ANTIBODY|Medicaid|MEDICAID|||||103.50||| 86708|EAP|0302|HEPATITIS A ANTIBODY TOTA|Managed Medicaid|MEDICAID SUPERIOR|||||474.75||| 86708|EAP|0302|HEPATITIS A ANTIBODY TOTA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||474.75||| 86708|EAP|0302|HEPATITIS A ANTIBODY TOTA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||474.75||| 86708|EAP|0302|HEPATITIS A ANTIBODY TOTA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||474.75||| 86708|EAP|0302|HEPATITIS A ANTIBODY TOTA|Managed Medicare|HEALTHSPRING MA|||||474.75||| 86708|EAP|0302|HEPATITIS A ANTIBODY TOTA|Managed Medicare|BCBS MEDICARE PPO MA|||||474.75||| 86708|EAP|0302|HEPATITIS A ANTIBODY TOTA|Medicaid|MEDICAID|474.75||||474.75||| 86708|EAP|0302|HEPATITIS A ANTIBODY TOTA|NON CONTRACTED|COMMERCIAL OTHER 1|||||474.75||| 86708|EAP|0302|HEPATITIS A ANTIBODY TOTA|Medicare|MEDICARE ACUTE|474.75||||474.75||| 86708|EAP|0302|HEPATITIS A ANTIBODY TOTA|United Healthcare|UNITED HEALTHCARE|||||474.75||| 86708|EAP|0302|HEPATITIS A ANTIBODY TOTA|United Healthcare|TML GROUP BENEFITS|||||474.75||| 86708|EAP|0302|HEPATITIS A ANTIBODY TOTA|United Medicare Advantage|UHC MEDICARE GOLD MA|||||474.75||| 86708|EAP|0302|HEPATITIS A ANTIBODY TOTA|Managed Medicaid|MEDICAID AMERIGROUP|474.75||||474.75||| 86708|EAP|0302|HEPATITIS A ANTIBODY TOTA|United Medicare Advantage|AARP UHC WEST COMPLETE MA|474.75||||474.75||| 86708|EAP|0302|HEPATITIS A ANTIBODY TOTA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|474.75||||474.75||| 86708|EAP|0302|HEPATITIS A ANTIBODY TOTA|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||474.75||| 86708|EAP|0302|HEPATITIS A ANTIBODY TOTA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||474.75||| 86708|EAP|0302|HEPATITIS A ANTIBODY TOTA|Aenta Medicare Advantage|AETNA MEDICARE MA|||||474.75||| 86708|EAP|0302|HEPATITIS A ANTIBODY TOTA|Access Direct Platinum|HEALTHFIRST TPA UMR|||||474.75||| 86708|EAP|0302|HEPATITIS A ANTIBODY TOTA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||474.75||| 86708|EAP|0302|HEPATITIS A ANTIBODY TOTA|Blue Cross HMO Specialty|BCBSTX HMO|||||474.75||| 86708|EAP|0302|HEPATITIS A ANTIBODY TOTA|Humana Medicare Advantage|HUMANA MA|474.75||||474.75||| 86708|EAP|0302|HEPATITIS A ANTIBODY TOTA|Blue Cross PPO Specialty|BCBSTX OTHER|||||474.75||| 86708|EAP|0302|HEPATITIS A ANTIBODY TOTA|Blue Cross PPO Specialty|BCBSTX PPO|||||474.75||| 86709|EAP|0302|HEPATITIS A AB IGM|Blue Cross PPO Specialty|BCBSTX OTHER|||||100.50||| 86709|EAP|0302|HEPATITIS A AB IGM|Blue Cross PPO Specialty|BCBSTX PPO|||||100.50||| 86709|EAP|0302|HEPATITIS A AB IGM|Humana Medicare Advantage|HUMANA MA|||||100.50||| 86709|EAP|0302|HEPATITIS A AB IGM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||100.50||| 86709|EAP|0302|HEPATITIS A AB IGM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||100.50||| 86709|EAP|0302|HEPATITIS A AB IGM|Access Direct Platinum|HEALTHFIRST TPA UMR|||||100.50||| 86709|EAP|0302|HEPATITIS A AB IGM|Blue Cross HMO Specialty|BCBSTX HMO|||||100.50||| 86709|EAP|0302|HEPATITIS A AB IGM|United Medicare Advantage|UHC MEDICARE GOLD MA|||||100.50||| 86709|EAP|0302|HEPATITIS A AB IGM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|431.25||||100.50||| 86709|EAP|0302|HEPATITIS A AB IGM|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||100.50||| 86709|EAP|0302|HEPATITIS A AB IGM|United Healthcare|UNITED HEALTHCARE|||||100.50||| 86709|EAP|0302|HEPATITIS A AB IGM|Aenta Medicare Advantage|AETNA MEDICARE MA|||||100.50||| 86709|EAP|0302|HEPATITIS A AB IGM|United Healthcare|TML GROUP BENEFITS|||||100.50||| 86709|EAP|0302|HEPATITIS A AB IGM|United Medicare Advantage|AARP UHC WEST COMPLETE MA|431.25||||100.50||| 86709|EAP|0302|HEPATITIS A AB IGM|Workers Compensation|WORKERS COMPENSATION OTHER|||||431.25||| 86709|EAP|0302|HEPATITIS A AB IGM|Workers Compensation|UT EMPLOYEE INJURY|||||431.25||| 86709|EAP|0302|HEPATITIS A AB IGM|NON CONTRACTED|COMMERCIAL OTHER 1|||||100.50||| 86709|EAP|0302|HEPATITIS A AB IGM|Rusk State Hospital|RUSK STATE HOSP|||||100.50||| 86709|EAP|0302|HEPATITIS A AB IGM|Medicare|MEDICARE ACUTE|100.50||||100.50||| 86709|EAP|0302|HEPATITIS A AB IGM|Managed Medicaid|MEDICAID SUPERIOR|||||100.50||| 86709|EAP|0302|HEPATITIS A AB IGM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||100.50||| 86709|EAP|0302|HEPATITIS A AB IGM|Managed Medicaid|MEDICAID AMERIGROUP|431.25||||100.50||| 86709|EAP|0302|HEPATITIS A AB IGM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||100.50||| 86709|EAP|0302|HEPATITIS A AB IGM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||100.50||| 86709|EAP|0302|HEPATITIS A AB IGM|Managed Medicare|HEALTHSPRING MA|||||100.50||| 86709|EAP|0302|HEPATITIS A AB IGM|Managed Medicare|BCBS MEDICARE PPO MA|||||100.50||| 86709|EAP|0302|HEPATITIS A AB IGM|Medicaid|MEDICAID|431.25||||100.50||| 86735|EAP|0302|MUMPS IGG|Managed Medicaid|MEDICAID SUPERIOR|||||116.75||| 86735|EAP|0302|MUMPS VIRUS IGG & IGM ANT|Medicare|MEDICARE ACUTE|||||116.75||| 86735|EAP|0302|MUMPS IGG|Tricare|TRICARE FOR LIFE|||||116.75||| 86735|EAP|0302|MUMPS IGG|NON CONTRACTED|COMMERCIAL OTHER 1|||||116.75||| 86735|EAP|0302|MUMPS VIRUS IGG & IGM ANT|NON CONTRACTED|COMMERCIAL OTHER 1|||||116.75||| 86735|EAP|0302|MUMPS IGG|United Healthcare|UNITED HEALTHCARE|||||116.75||| 86735|EAP|0302|MUMPS IGG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||116.75||| 86735|EAP|0302|MUMPS IGG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||116.75||| 86735|EAP|0302|MUMPS IGG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||116.75||| 86735|EAP|0302|MUMPS IGG|Blue Cross HMO Specialty|BCBSTX HMO|||||116.75||| 86735|EAP|0302|MUMPS VIRUS IGG & IGM ANT|Blue Cross HMO Specialty|BCBSTX HMO|||||116.75||| 86735|EAP|0302|MUMPS IGG|Blue Cross PPO Specialty|BCBSTX PPO|||||116.75||| 86738|EAP|0302|MYCOPLASMA PNEUMONIAE IG|Humana Medicare Advantage|HUMANA MA|10.15||||||| 86738|EAP|0302|MYCOPLASMA PNEUMONIAE IG|Blue Cross PPO Specialty|BCBSTX PPO|10.15||||||| 86738|EAP|0302|MYCOPLASMA PNEUMONIAE IG|Blue Cross HMO Specialty|BCBSTX HMO|||||236.75||| 86738|EAP|0302|MYCOPLASMA PNEUMONIAE IG|Aenta Medicare Advantage|AETNA MEDICARE MA|10.15||||||| 86738|EAP|0302|MYCOPLASMA PNEUMONIAE IG|United Medicare Advantage|AARP UHC WEST COMPLETE MA|10.15||||||| 86738|EAP|0302|MYCOPLASMA PNEUMONIAE IG|NON CONTRACTED|COMMERCIAL OTHER 1|10.15||||||| 86738|EAP|0302|MYCOPLASMA PNEUMONIAE IG|Medicare|MEDICARE ACUTE|10.15||||||| 86747|EAP|0302|PARVOVIRUS ANTIBODY B19 I|Managed Medicaid|MEDICAID SUPERIOR|||||134.25||| 86747|EAP|0302|PARVOVIURS ANTIBODY B19 I|Managed Medicaid|MEDICAID SUPERIOR|||||5.76||| 86747|EAP|0302|PARVOVIRUS ANTIBODY B19 I|NON CONTRACTED|COMMERCIAL OTHER 1|||||134.25||| 86747|EAP|0302|PARVOVIURS ANTIBODY B19 I|NON CONTRACTED|COMMERCIAL OTHER 1|||||5.76||| 86757|EAP|0302|RICKETTSIA AB PANEL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||183.50||| 86757|EAP|0300|ROCKY MT SPOTTED FEVER AB|United Medicare Advantage|UHC MEDICARE GOLD MA|||||62.50||| 86757|EAP|0300|ROCKY MT SPOTTED FEVER AB|Blue Cross PPO Specialty|BCBSTX PPO|||||62.50||| 86762|EAP|0302|RUBELLA IGG|NON CONTRACTED|COMMERCIAL OTHER 1|||||128.75||| 86762|EAP|0302|RUBELLA IGG|Tricare|TRICARE EAST REGION|||||128.75||| 86762|EAP|0302|RUBELLA IGG|Medicare|MEDICARE ACUTE|||||128.75||| 86762|EAP|0302|RUBELLA IGG|Tricare|TRICARE FOR LIFE|||||128.75||| 86762|EAP|0302|RUBELLA IGG|Managed Medicaid|MEDICAID AMERIGROUP|551.50||||128.75||| 86762|EAP|0302|RUBELLA IGG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||128.75||| 86762|EAP|0302|RUBELLA IGG|Managed Medicaid|MEDICAID SUPERIOR|551.50||||128.75||| 86762|EAP|0302|RUBELLA IGG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||128.75||| 86762|EAP|0302|RUBELLA IGG|Medicaid|MEDICAID HMO|||||128.75||| 86762|EAP|0302|RUBELLA IGG|Medicaid|MEDICAID|551.50||||128.75||| 86762|EAP|0302|RUBELLA IGG|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||128.75||| 86762|EAP|0302|RUBELLA IGG|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||128.75||| 86762|EAP|0302|RUBELLA IGG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||128.75||| 86762|EAP|0302|RUBELLA IGG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||128.75||| 86762|EAP|0302|RUBELLA IGG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||128.75||| 86762|EAP|0302|RUBELLA IGG|NON CONTRACTED|COMMERCIAL OTHER 2|||||128.75||| 86762|EAP|0302|RUBELLA IGG|Blue Cross HMO Specialty|BCBSTX HMO|||||128.75||| 86762|EAP|0302|RUBELLA IGG|Aetna|AETNA PPO|||||128.75||| 86762|EAP|0302|RUBELLA IGG|Aenta Medicare Advantage|AETNA MEDICARE MA|||||128.75||| 86762|EAP|0302|RUBELLA IGG|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||128.75||| 86762|EAP|0302|RUBELLA IGG|Blue Cross PPO Specialty|BCBSTX PPO|||||128.75||| 86762|EAP|0302|RUBELLA IGG|Blue Cross PPO Specialty|BCBSTX OTHER|||||128.75||| 86762|EAP|0302|RUBELLA IGG|Humana Medicare Advantage|HUMANA MA|||||128.75||| 86762|EAP|0302|RUBELLA IGG|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||128.75||| 86762|EAP|0302|RUBELLA IGG|United Healthcare|UNITED HEALTHCARE OTHER|||||128.75||| 86762|EAP|0302|RUBELLA IGG|United Healthcare|UNITED HEALTHCARE|||||128.75||| 86765|EAP|0300|RUBEOLA IGG|United Healthcare|UNITED HEALTHCARE|||||115.25||| 86765|EAP|0300|RUBEOLA IGG|Blue Cross PPO Specialty|BCBSTX PPO|||||115.25||| 86765|EAP|0300|RUBEOLA IGG|Blue Cross HMO Specialty|BCBSTX HMO|||||115.25||| 86765|EAP|0300|RUBEOLU (MEASLES) IGM ANI|Blue Cross HMO Specialty|BCBSTX HMO|||||115.25||| 86765|EAP|0300|RUBEOLA IGG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||115.25||| 86765|EAP|0300|RUBEOLA IGG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||115.25||| 86765|EAP|0300|RUBEOLA IGG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||115.25||| 86765|EAP|0300|RUBEOLA IGG|Managed Medicaid|MEDICAID SUPERIOR|||||115.25||| 86765|EAP|0300|RUBEOLA IGG|NON CONTRACTED|COMMERCIAL OTHER 1|||||115.25||| 86765|EAP|0300|RUBEOLA IGG|Tricare|TRICARE FOR LIFE|||||115.25||| 86768|EAP|0300|SALMONELLA AGG (WIDAL)|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.67||| 86769|EAP|0300|COVID-19 TOTAL ANTIBODY|Tricare|TRICARE EAST REGION|||||84.26||| 86769|EAP|0300|SARS/COVID-19,IGG/IGM/IGA|NON CONTRACTED|COMMERCIAL OTHER 1|||||84.26||| 86769|EAP|0300|SARS/COVID-19,IGG/IGM/IGA|Medicare|MEDICARE ACUTE|||||84.26||| 86769|EAP|0300|COVID-19 TOTAL ANTIBODY|Medicaid|SUPERIOR HEALTHPLAN CHIP|84.26||||||| 86769|EAP|0300|SARS/COVID-19,IGG/IGM/IGA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||84.26||| 86769|EAP|0300|SARS/COVID-19,IGG/IGM/IGA|Managed Medicaid|MEDICAID SUPERIOR|||||84.26||| 86769|EAP|0300|SARS/COVID-19,IGG/IGM/IGA|Managed Medicaid|MEDICAID AMERIGROUP|||||84.26||| 86769|EAP|0300|COVID-19 TOTAL ANTIBODY|Managed Medicaid|MEDICAID SUPERIOR|||||84.26||| 86769|EAP|0300|SARS/COVID-19,IGG/IGM/IGA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||84.26||| 86769|EAP|0300|COVID-19 TOTAL ANTIBODY|Medicare|MEDICARE ACUTE|||||84.26||| 86769|EAP|0300|COVID-19 TOTAL ANTIBODY|Blue Cross HMO Specialty|BCBSTX HMO|||||84.26||| 86769|EAP|0300|SARS/COVID-19,IGG/IGM/IGA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||84.26||| 86769|EAP|0300|COVID-19 TOTAL ANTIBODY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||84.26||| 86769|EAP|0300|SARS/COVID-19,IGG/IGM/IGA|Blue Cross HMO Specialty|BCBSTX HMO|||||84.26||| 86769|EAP|0300|SARS/COVID-19,IGG/IGM/IGA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||84.26||| 86769|EAP|0300|COVID-19 TOTAL ANTIBODY|Humana Medicare Advantage|HUMANA MA|||||84.26||| 86769|EAP|0300|COVID-19 TOTAL ANTIBODY|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||84.26||| 86769|EAP|0300|SARS/COVID-19,IGG/IGM/IGA|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||84.26||| 86769|EAP|0300|SARS/COVID-19,IGG/IGM/IGA|Blue Cross PPO Specialty|BCBSTX PPO|||||84.26||| 86769|EAP|0300|COVID-19 TOTAL ANTIBODY|Blue Cross PPO Specialty|BCBSTX PPO|||||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|United Healthcare|TML GROUP BENEFITS|||||84.26||| 86769|EAP|0300|SARS/COVID-19,IGG/IGM/IGA|United Healthcare|GOLDEN RULE|||||84.26||| 86774|EAP|0306|TETANUS ANTITOXOID BY ELI|Managed Medicaid|MEDICAID SUPERIOR|||||132.25||| 86777|EAP|0302|TOXOPLASMA IGG ANTIBODY|Humana Medicare Advantage|HUMANA MA|||||128.75||| 86777|EAP|0302|TOXOPLASMA IGG ANTIBODY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||128.75||| 86777|EAP|0302|TOXOPLASMA IGG ANTIBODY|Blue Cross HMO Specialty|BCBSTX HMO|||||128.75||| 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|||||114.25||| 86778|EAP|0302|TOXOPLASMA IGM ANTIBODIES|Blue Cross HMO Specialty|BCBSTX HMO|||||114.25||| 86778|EAP|0302|TOXOPLASMA IGM ANTIBODIES|Humana Medicare Advantage|HUMANA MA|||||114.25||| 86780|EAP|0300|FTA ABS|Humana Medicare Advantage|HUMANA MA|||||79.75||| 86780|EAP|0300|FTA ABS|Blue Cross HMO Specialty|BCBSTX HMO|||||79.75||| 86780|EAP|0302|SYPHILIS IGG & IGM SERUM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||79.75||| 86780|EAP|0300|FTA ABS|Managed Medicaid|MEDICAID SUPERIOR|||||335.25||| 86780|EAP|0300|FTA ABS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||79.75||| 86787|EAP|0302|VARCELLA ZOSTER IG G|NON CONTRACTED|COMMERCIAL OTHER 2|||||0.73||| 86787|EAP|0302|VARCELLA ZOSTER IG G|Tricare|TRICARE EAST REGION|||||0.73||| 86787|EAP|0302|VARCELLA ZOSTER IG G|Medicare|MEDICARE ACUTE|||||0.73||| 86787|EAP|0302|VARCELLA ZOSTER IG G|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.73||| 86787|EAP|0302|VARCELLA ZOSTER IG G|Managed Medicaid|MEDICAID AMERIGROUP|||||0.73||| 86787|EAP|0302|VARCELLA ZOSTER IG G|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.73||| 86787|EAP|0302|VARCELLA ZOSTER IG G|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.73||| 86787|EAP|0302|VARCELLA ZOSTER IG G|Medicaid|MEDICAID|||||0.73||| 86787|EAP|0302|VARCELLA ZOSTER IG G|Medicaid|MEDICAID HMO|||||0.73||| 86787|EAP|0302|VARCELLA ZOSTER IG G|Managed Medicaid|MEDICAID SUPERIOR|||||0.73||| 86787|EAP|0302|VARCELLA ZOSTER IG G|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.73||| 86787|EAP|0302|VARCELLA ZOSTER IG G|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||0.73||| 86787|EAP|0302|VARCELLA ZOSTER IG G|Tricare|TRICARE FOR LIFE|||||0.73||| 86787|EAP|0302|VARCELLA ZOSTER IG G|United Healthcare|UNITED HEALTHCARE OTHER|||||0.73||| 86787|EAP|0302|VARCELLA ZOSTER IG G|United Healthcare|UNITED HEALTHCARE|||||0.73||| 86787|EAP|0302|VARCELLA ZOSTER IG G|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.73||| 86787|EAP|0302|VARCELLA ZOSTER IG G|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.73||| 86787|EAP|0302|VARCELLA ZOSTER IG G|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.73||| 86787|EAP|0302|VARICELLA ZOSTER IGG&IGM|Blue Cross HMO Specialty|BCBSTX HMO|||||0.73||| 86787|EAP|0302|VARCELLA ZOSTER IG G|Blue Cross HMO Specialty|BCBSTX HMO|||||0.73||| 86787|EAP|0302|VARCELLA ZOSTER IG G|Aetna|AETNA PPO|||||0.73||| 86787|EAP|0300|VARICELLA ZOSTER, IGM AB|Blue Cross HMO Specialty|BCBSTX HMO|||||0.73||| 86787|EAP|0300|VARICELLA ZOSTER, IGM AB|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.73||| 86787|EAP|0302|VARCELLA ZOSTER IG G|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||0.73||| 86787|EAP|0302|VARCELLA ZOSTER IG G|Blue Cross PPO Specialty|BCBSTX PPO|||||0.73||| 86787|EAP|0302|VARCELLA ZOSTER IG G|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.73||| 86787|EAP|0302|VARCELLA ZOSTER IG G|Humana Medicare Advantage|HUMANA MA|||||0.73||| 86788|EAP|0300|WEST NILE VIRUS IGM|Blue Cross PPO Specialty|BCBSTX PPO|||||0.73||| 86789|EAP|0300|WEST NILE VIRUS IGG|Blue Cross PPO Specialty|BCBSTX PPO|||||128.75||| 86800|EAP|0302|THYROGLOBULIN ANTIBODY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||142.25||| 86800|EAP|0302|THYROGLOBULIN ANTIBODY|Managed Medicaid|MEDICAID SUPERIOR|||||142.25||| 86800|EAP|0302|THYROGLOBULIN ANTIBODY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||142.25||| 86800|EAP|0302|THYROGLOBULIN ANTIBODY|Managed Medicaid|MEDICAID AMERIGROUP|||||142.25||| 86800|EAP|0300|THYROID AUTOANTIBODIES|Managed Medicaid|MEDICAID SUPERIOR|||||142.25||| 86800|EAP|0300|THYROID AUTOANTIBODIES|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||142.25||| 86800|EAP|0302|THYROGLOBULIN ANTIBODY|Medicaid|MEDICAID|||||142.25||| 86800|EAP|0300|THYROID AUTOANTIBODIES|Medicare|MEDICARE ACUTE|||||142.25||| 86800|EAP|0302|THYROGLOBULIN ANTIBODY|Medicare|MEDICARE ACUTE|||||142.25||| 86800|EAP|0302|THYROGLOBULIN ANTIBODY|United Healthcare|TML GROUP BENEFITS|||||142.25||| 86800|EAP|0302|THYROGLOBULIN ANTIBODY|United Medicare Advantage|UHC MEDICARE GOLD MA|||||142.25||| 86800|EAP|0302|THYROGLOBULIN ANTIBODY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||142.25||| 86800|EAP|0302|THYROGLOBULIN ANTIBODY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||142.25||| 86800|EAP|0302|THYROGLOBULIN ANTIBODY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||142.25||| 86800|EAP|0302|THYROGLOBULIN ANTIBODY|Humana Medicare Advantage|HUMANA MA|||||142.25||| 86800|EAP|0302|THYROGLOBULIN ANTIBODY|Blue Cross PPO Specialty|BCBSTX PPO|||||142.25||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||127.50||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Humana Medicare Advantage|HUMANA MA|5.47||||127.50||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Blue Cross PPO Specialty|BCBSTX PPO|||||127.50||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Blue Cross PPO Specialty|BCBSTX OTHER|||||127.50||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Cigna|CIGNA|||||127.50||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Aetna|AETNA PPO|||||127.50||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Access Direct Platinum|HEALTHFIRST TPA UMR|||||127.50||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||127.50||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Blue Cross HMO Specialty|BCBSTX HMO|||||127.50||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||127.50||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||127.50||| 86803|EAP|0302|HEPATITIS C ANTIBODY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.47||||127.50||| 86803|EAP|0302|HEPATITIS C ANTIBODY|United Healthcare|UNITED HEALTHCARE|||||127.50||| 86803|EAP|0302|HEPATITIS C ANTIBODY|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||127.50||| 86803|EAP|0302|HEPATITIS C ANTIBODY|United Healthcare|TML GROUP BENEFITS|||||127.50||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Aenta Medicare Advantage|AETNA MEDICARE MA|||||127.50||| 86803|EAP|0302|HEPATITIS C ANTIBODY|United Medicare Advantage|AARP UHC WEST COMPLETE MA|5.47||||127.50||| 86803|EAP|0302|HEPATITIS C ANTIBODY|United Medicare Advantage|UHC MEDICARE GOLD MA|||||127.50||| 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|Medicare|MEDICARE ACUTE|5.47||||127.50||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Tricare|TRICARE EAST REGION|||||127.50||| 86803|EAP|0302|HEPATITIS C ANTIBODY|NON CONTRACTED|COMMERCIAL OTHER 1|||||127.50||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Rusk State Hospital|RUSK STATE HOSP|||||127.50||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.47||||127.50||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Managed Medicaid|MEDICAID SUPERIOR|5.47||||127.50||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.47||||127.50||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Managed Medicaid|MEDICAID AMERIGROUP|5.47||||127.50||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||127.50||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||127.50||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Managed Medicare|HEALTHSPRING MA|||||127.50||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Managed Medicare|BCBS MEDICARE PPO MA|||||127.50||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Medicaid|MEDICAID HMO|||||127.50||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Medicaid|MEDICAID|5.47||||127.50||| 86803|EAP|0302|HEPATITIS C ANTIBODY|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||127.50||| 86812|EAP|0302|HLA - B-27|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||230.75||| 86812|EAP|0302|HLA - B-27|Managed Medicaid|MEDICAID AMERIGROUP|||||230.75||| 86812|EAP|0302|HLA - B-27|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||230.75||| 86812|EAP|0302|HLA - B-27|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||230.75||| 86812|EAP|0302|HLA - B-27|Blue Cross PPO Specialty|BCBSTX PPO|||||230.75||| 86850|EAP|0302|ANTIBODY SCREEN|United Medicare Advantage|UHC MEDICARE GOLD MA|345.25||||345.25||| 86850|EAP|0302|ANTIBODY SCREEN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|345.25||||345.25||| 86850|EAP|0302|ANTIBODY SCREEN|United Healthcare|UNITED HEALTHCARE|345.25||||345.25||| 86850|EAP|0302|ANTIBODY SCREEN|United Medicare Advantage|AARP UHC WEST COMPLETE MA|345.25||||345.25||| 86850|EAP|0302|ANTIBODY SCREEN|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|345.25||||||| 86850|EAP|0302|ANTIBODY SCREEN|Humana Medicare Advantage|HUMANA MA|345.25||||345.25||| 86850|EAP|0302|ANTIBODY SCREEN|Blue Cross PPO Specialty|BCBSTX OTHER|||||345.25||| 86850|EAP|0302|ANTIBODY SCREEN|Blue Cross PPO Specialty|BCBSTX PPO|345.25||||0.82||| 86850|EAP|0302|ANTIBODY SCREEN|Cigna|CIGNA|345.25||||||| 86850|EAP|0302|ANTIBODY SCREEN|Blue Cross HMO Specialty|BCBSTX HMO|345.25||||0.82||| 86850|EAP|0302|ANTIBODY SCREEN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|345.25||||0.82||| 86850|EAP|0302|ANTIBODY SCREEN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|345.25||||213.63||| 86850|EAP|0302|ANTIBODY SCREEN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|345.25||||0.82||| 86850|EAP|0302|ANTIBODY SCREEN|Aenta Medicare Advantage|AETNA MEDICARE MA|345.25||||213.63||| 86850|EAP|0302|ANTIBODY SCREEN|Aetna|AETNA PPO|345.25||||0.82||| 86850|EAP|0302|ANTIBODY SCREEN|NON CONTRACTED|COMMERCIAL OTHER 2|||||0.82||| 86850|EAP|0302|ANTIBODY SCREEN|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|345.25||||0.82||| 86850|EAP|0302|ANTIBODY SCREEN|Tricare|TRICARE EAST REGION|345.25||||0.82||| 86850|EAP|0302|ANTIBODY SCREEN|NON CONTRACTED|COMMERCIAL OTHER 1|345.25||||0.82||| 86850|EAP|0302|ANTIBODY SCREEN|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|345.25||||||| 86850|EAP|0302|ANTIBODY SCREEN|UTMB|UTMB CORRECTIONAL MANAGED CARE|345.25||||345.25||| 86850|EAP|0302|ANTIBODY SCREEN|United Healthcare|UNITED HEALTHCARE OTHER|345.25||||0.82||| 86850|EAP|0302|ANTIBODY SCREEN|Medicare|MEDICARE ACUTE|345.25||||345.25||| 86850|EAP|0302|ANTIBODY SCREEN|Managed Medicaid|MEDICAID AMERIGROUP|345.25||||0.82||| 86850|EAP|0302|ANTIBODY SCREEN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|345.25||||0.82||| 86850|EAP|0302|ANTIBODY SCREEN|Managed Medicaid|MEDICAID SUPERIOR|345.25||||0.82||| 86850|EAP|0302|ANTIBODY SCREEN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|345.25||||345.25||| 86850|EAP|0302|ANTIBODY SCREEN|Managed Medicare|HEALTHSPRING MA|345.25||||||| 86850|EAP|0302|ANTIBODY SCREEN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||345.25||| 86850|EAP|0302|ANTIBODY SCREEN|Medicaid|MEDICAID|345.25||||0.82||| 86850|EAP|0302|ANTIBODY SCREEN|Medicaid|MOLINA HEALTHCARE OF TEXAS|345.25||||0.82||| 86850|EAP|0302|ANTIBODY SCREEN|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.82||| 86850|EAP|0302|ANTIBODY SCREEN|Medicaid|MEDICAID HMO|||||213.63||| 86860|EAP|0300|ELUTION, BLOOD BANK|Medicare|MEDICARE ACUTE|580.25||||||| 86870|EAP|0302|ANTIBODY ID RBC AB/@PANEL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||580.25||| 86870|EAP|0302|ANTIBODY ID RBC AB/@PANEL|Medicare|MEDICARE ACUTE|580.25||||||| 86880|EAP|0302|DIRECT COOMBS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|180.25||||||| 86880|EAP|0302|DIRECT COOMBS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|180.25||||||| 86880|EAP|0302|DIRECT COOMBS|Blue Cross HMO Specialty|BCBSTX HMO|180.25||||180.25||| 86880|EAP|0302|DIRECT COOMBS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|180.25||||||| 86880|EAP|0302|DIRECT COOMBS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|180.25||||||| 86880|EAP|0302|DIRECT COOMBS|Cigna|CIGNA|180.25||||||| 86880|EAP|0302|DIRECT COOMBS|Blue Cross PPO Specialty|BCBSTX PPO|180.25||||||| 86880|EAP|0302|DIRECT COOMBS|United Healthcare|UNITED HEALTHCARE OTHER|180.25||||||| 86880|EAP|0302|DIRECT COOMBS|United Healthcare|UNITED HEALTHCARE|180.25||||||| 86880|EAP|0302|DIRECT COOMBS|Medicare|MEDICARE ACUTE|180.25||||||| 86880|EAP|0302|DIRECT COOMBS|NON CONTRACTED|COMMERCIAL OTHER 1|180.25||||||| 86880|EAP|0302|DIRECT COOMBS|Tricare|TRICARE EAST REGION|180.25||||||| 86880|EAP|0302|DIRECT COOMBS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|180.25||||||| 86880|EAP|0302|DIRECT COOMBS|Managed Medicaid|MEDICAID SUPERIOR|180.25||||||| 86880|EAP|0302|DIRECT COOMBS|Managed Medicaid|MEDICAID AMERIGROUP|180.25||||||| 86880|EAP|0302|DIRECT COOMBS|Medicaid|MEDICAID|180.25||||||| 86880|EAP|0302|DIRECT COOMBS|Medicaid|MOLINA HEALTHCARE OF TEXAS|180.25||||||| 86886|EAP|0300|ANTIBODY TITER|Medicaid|MEDICAID|||||46.25||| 86886|EAP|0300|ANTIBODY TITER|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||46.25||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|180.25||||||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|United Medicare Advantage|UHC MEDICARE GOLD MA|180.25||||180.25||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|United Medicare Advantage|AARP UHC WEST COMPLETE MA|180.25||||180.25||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|United Healthcare|UNITED HEALTHCARE OTHER|180.25||||42.75||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|United Healthcare|UNITED HEALTHCARE|180.25||||180.25||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|180.25||||180.25||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|180.25||||42.75||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Humana Medicare Advantage|HUMANA MA|180.25||||180.25||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Cigna|CIGNA|180.25||||||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|180.25||||42.75||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Aetna|AETNA PPO|180.25||||42.75||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|180.25||||111.50||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Blue Cross PPO Specialty|BCBSTX OTHER|||||180.25||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|180.25||||42.75||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Aenta Medicare Advantage|AETNA MEDICARE MA|180.25||||180.25||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Blue Cross HMO Specialty|BCBSTX HMO|180.25||||42.75||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|NON CONTRACTED|COMMERCIAL OTHER 2|||||42.75||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Blue Cross PPO Specialty|BCBSTX PPO|180.25||||42.75||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|NON CONTRACTED|COMMERCIAL OTHER 1|180.25||||42.75||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|180.25||||||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Medicare|MEDICARE ACUTE|180.25||||180.25||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Tricare|TRICARE EAST REGION|180.25||||42.75||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|UTMB|UTMB CORRECTIONAL MANAGED CARE|180.25||||180.25||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Managed Medicaid|MEDICAID UNITED HEALTHCARE|180.25||||42.75||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Managed Medicaid|MEDICAID SUPERIOR|180.25||||42.75||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|180.25||||180.25||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Managed Medicaid|MEDICAID AMERIGROUP|180.25||||42.75||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||42.75||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Medicaid|MEDICAID HMO|||||111.50||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||180.25||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Managed Medicare|HOSPICE OF EAST TEXAS|180.25||||||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Managed Medicare|HEALTHSPRING MA|180.25||||||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Medicaid|MOLINA HEALTHCARE OF TEXAS|180.25||||42.75||| 86900|EAP|0302|BLOOD TYPE (ABO GROUP)|Medicaid|MEDICAID|180.25||||42.75||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||42.75||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Medicaid|MEDICAID HMO|||||111.50||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||180.25||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Managed Medicare|HOSPICE OF EAST TEXAS|180.25||||||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|180.25||||111.50||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Managed Medicare|HEALTHSPRING MA|180.25||||||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|180.25||||180.25||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Managed Medicaid|MEDICAID AMERIGROUP|180.25||||42.75||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Medicaid|MOLINA HEALTHCARE OF TEXAS|180.25||||42.75||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|NON CONTRACTED|COMMERCIAL OTHER 2|||||42.75||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Medicare|MEDICARE ACUTE|180.25||||180.25||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|180.25||||||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Tricare|TRICARE EAST REGION|180.25||||42.75||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|NON CONTRACTED|COMMERCIAL OTHER 1|180.25||||42.75||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|UTMB|UTMB CORRECTIONAL MANAGED CARE|180.25||||180.25||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Managed Medicaid|MEDICAID SUPERIOR|180.25||||42.75||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Aenta Medicare Advantage|AETNA MEDICARE MA|180.25||||180.25||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Blue Cross HMO Specialty|BCBSTX HMO|180.25||||111.50||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|180.25||||111.50||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Aetna|AETNA PPO|180.25||||42.75||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|180.25||||111.50||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|180.25||||42.75||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|180.25||||111.50||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Blue Cross PPO Specialty|BCBSTX PPO|180.25||||42.75||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Medicaid|MEDICAID|180.25||||42.75||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Humana Medicare Advantage|HUMANA MA|180.25||||180.25||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Cigna|CIGNA|180.25||||||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Blue Cross PPO Specialty|BCBSTX OTHER|||||180.25||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|United Healthcare|UNITED HEALTHCARE OTHER|180.25||||42.75||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|United Healthcare|UNITED HEALTHCARE|180.25||||180.25||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|United Medicare Advantage|UHC MEDICARE GOLD MA|180.25||||180.25||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|180.25||||180.25||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|United Medicare Advantage|AARP UHC WEST COMPLETE MA|180.25||||180.25||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|180.25||||||| 86901|EAP|0300|BLOOD TYPING RH FACTOR|Workers Compensation|WORKERS COMPENSATION OTHER|||||180.25||| 86922|EAP|0300|CROSSMATCH PANEL|United Healthcare|UNITED HEALTHCARE OTHER|580.25||||580.25||| 86922|EAP|0300|CROSSMATCH PANEL|United Medicare Advantage|UHC MEDICARE GOLD MA|580.25||||580.25||| 86922|EAP|0300|CROSSMATCH PANEL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|580.25||||||| 86922|EAP|0300|CROSSMATCH PANEL|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|580.25||||||| 86922|EAP|0300|CROSSMATCH PANEL|Cigna|CIGNA|580.25||||||| 86922|EAP|0300|CROSSMATCH PANEL|Humana Medicare Advantage|HUMANA MA|580.25||||580.25||| 86922|EAP|0300|CROSSMATCH PANEL|Blue Cross PPO Specialty|BCBSTX OTHER|||||580.25||| 86922|EAP|0300|CROSSMATCH PANEL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|580.25||||580.25||| 86922|EAP|0300|CROSSMATCH PANEL|Blue Cross PPO Specialty|BCBSTX PPO|580.25||||580.25||| 86922|EAP|0300|CROSSMATCH PANEL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|580.25||||||| 86922|EAP|0300|CROSSMATCH PANEL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|580.25||||580.25||| 86922|EAP|0300|CROSSMATCH PANEL|Aenta Medicare Advantage|AETNA MEDICARE MA|580.25||||||| 86922|EAP|0300|CROSSMATCH PANEL|United Healthcare|UNITED HEALTHCARE|580.25||||580.25||| 86922|EAP|0300|CROSSMATCH PANEL|Blue Cross HMO Specialty|BCBSTX HMO|580.25||||580.25||| 86922|EAP|0300|CROSSMATCH PANEL|NON CONTRACTED|COMMERCIAL OTHER 1|580.25||||580.25||| 86922|EAP|0300|CROSSMATCH PANEL|UTMB|UTMB CORRECTIONAL MANAGED CARE|580.25||||580.25||| 86922|EAP|0300|CROSSMATCH PANEL|Medicare|MEDICARE ACUTE|580.25||||580.25||| 86922|EAP|0300|CROSSMATCH PANEL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||580.25||| 86922|EAP|0300|CROSSMATCH PANEL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|580.25||||||| 86922|EAP|0300|CROSSMATCH PANEL|Managed Medicaid|MEDICAID SUPERIOR|580.25||||580.25||| 86922|EAP|0300|CROSSMATCH PANEL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|580.25||||580.25||| 86922|EAP|0300|CROSSMATCH PANEL|Managed Medicaid|MEDICAID AMERIGROUP|580.25||||1.49||| 86922|EAP|0300|CROSSMATCH PANEL|Medicaid|MOLINA HEALTHCARE OF TEXAS|580.25||||||| 86922|EAP|0300|CROSSMATCH PANEL|Medicaid|MEDICAID|580.25||||580.25||| 870|DRG||SEPTICEMIA OR SEVERE SEPSIS W MV >96 HOURS|Medicare|MEDICARE ACUTE|280,023.38|46269.56|65005.05|41773.405|||| 870|DRG||SEPTICEMIA OR SEVERE SEPSIS W MV >96 HOURS|Aenta Medicare Advantage|AETNA MEDICARE MA|254,867.24|41773.405|65005.05|41773.405|||| 870|DRG||SEPTICEMIA OR SEVERE SEPSIS W MV >96 HOURS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|517,345.26|65005.05|65005.05|41773.405|||| 870|DRG||SEPTICEMIA OR SEVERE SEPSIS W MV >96 HOURS|Humana Medicare Advantage|HUMANA MA|238,791.95|50838.65|65005.05|41773.405|||| 870|DRG||SEPTICEMIA OR SEVERE SEPSIS W MV >96 HOURS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|370,102.75|50610.53|65005.05|41773.405|||| 87015|EAP|0300|CONCENTRATION (ANY TYPE)|United Medicare Advantage|UHC MEDICARE GOLD MA|246.50||||||| 87015|EAP|0300|CONCENTRATION (ANY TYPE)|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|246.50||||||| 87015|EAP|0300|CONCENTRATION (ANY TYPE)|Blue Cross PPO Specialty|BCBSTX OTHER|246.50||||||| 87015|EAP|0300|CONCENTRATION (ANY TYPE)|Blue Cross PPO Specialty|BCBSTX PPO|246.50||||58.75||| 87015|EAP|0300|CONCENTRATION (ANY TYPE)|Humana Medicare Advantage|HUMANA MA|246.50||||||| 87015|EAP|0300|CONCENTRATION (ANY TYPE)|Aenta Medicare Advantage|AETNA MEDICARE MA|246.50||||58.75||| 87015|EAP|0300|CONCENTRATION (ANY TYPE)|Blue Cross HMO Specialty|BCBSTX HMO|246.50||||||| 87015|EAP|0300|CONCENTRATION (ANY TYPE)|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|246.50||||||| 87015|EAP|0300|CONCENTRATION (ANY TYPE)|Managed Medicaid|MEDICAID UNITED HEALTHCARE|246.50||||246.50||| 87015|EAP|0300|CONCENTRATION (ANY TYPE)|Managed Medicaid|MEDICAID SUPERIOR|246.50||||||| 87015|EAP|0300|CONCENTRATION (ANY TYPE)|Managed Medicaid|MEDICAID AMERIGROUP|246.50||||||| 87015|EAP|0300|CONCENTRATION (ANY TYPE)|Medicaid|MEDICAID|246.50||||246.50||| 87015|EAP|0300|CONCENTRATION (ANY TYPE)|Medicare|MEDICARE ACUTE|246.50||||58.75||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Managed Medicare|HEALTHSPRING MA|395.25||||||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Medicaid|MOLINA HEALTHCARE OF TEXAS|395.25||||||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Medicaid|COUNTY INDIGENT HEALTH OTHER|395.25||||||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Medicaid|MEDICAID TEXAS CHILDRENS|||||395.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Medicaid|MEDICAID|395.25||||395.25||| 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|Aenta Medicare Advantage|AETNA MEDICARE MA|395.25||||395.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||395.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Aetna|AETNA PPO|395.25||||395.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Blue Cross HMO Specialty|BCBSTX HMO|395.25||||395.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|395.25||||395.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|395.25||||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|Aetna|AETNA OTHER|395.25||||||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Medicaid|SUPERIOR HEALTHPLAN CHIP|395.25||||395.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Blue Cross PPO Specialty|BCBSTX PPO|395.25||||395.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Cigna|CIGNA|||||395.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Medicaid|MEDICAID HMO|||||395.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Blue Cross PPO Specialty|BCBSTX OTHER|395.25||||395.25||| 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 Healthcare|UNITED HEALTHCARE|395.25||||395.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|United Healthcare|UNITED HEALTHCARE|||||395.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|United Healthcare|UMR UNITED MEDICAL RESOURCES|395.25||||395.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|395.25||||395.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Veterans Affairs|VETERANS ADMINISTRATION|395.25||||395.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Workers Compensation|UT EMPLOYEE INJURY|395.25||||||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Workers Compensation|WORKERS COMPENSATION OTHER|||||395.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|395.25||||||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|United Medicare Advantage|AARP UHC WEST COMPLETE MA|395.25||||395.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Managed Medicaid|MEDICAID UNITED HEALTHCARE|395.25||||395.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|UTMB|UTMB CORRECTIONAL MANAGED CARE|395.25||||395.25||| 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|NON CONTRACTED|COMMERCIAL OTHER 1|395.25||||395.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||395.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Tricare|TRICARE EAST REGION|||||395.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Rusk State Hospital|RUSK STATE HOSP|395.25||||395.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Medicare|MEDICARE ACUTE|395.25||||395.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Managed Medicaid|MEDICAID SUPERIOR|395.25||||395.25||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Managed Medicaid|MEDICAID AMERIGROUP|395.25||||395.25||| 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|Managed Medicare|HOSPICE OF EAST TEXAS|395.25||||||| 87040|EAP|0306|CULTURE BLOOD W/ISO&PRESU|Medicare|MEDICARE PART B ONLY IP|395.25||||||| 87046|EAP|0306|CULTURE, STOOL|Medicaid|MEDICAID|361.25||||||| 87046|EAP|0306|CULTURE, STOOL|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||84.25||| 87046|EAP|0306|CULTURE, STOOL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||84.25||| 87046|EAP|0306|CULTURE, STOOL|Humana Medicare Advantage|HUMANA MA|361.25||||84.25||| 87046|EAP|0306|CULTURE, STOOL|Medicaid|MOLINA HEALTHCARE OF TEXAS|361.25||||||| 87046|EAP|0306|CULTURE, STOOL|Managed Medicaid|MEDICAID SUPERIOR|361.25||||84.25||| 87046|EAP|0306|CULTURE, STOOL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|361.25||||84.25||| 87046|EAP|0306|CULTURE, STOOL|Managed Medicaid|MEDICAID AMERIGROUP|||||84.25||| 87046|EAP|0306|CULTURE, STOOL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|361.25||||84.25||| 87046|EAP|0306|CULTURE, STOOL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||361.25||| 87046|EAP|0306|CULTURE, STOOL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||84.25||| 87046|EAP|0306|CULTURE, STOOL|Blue Cross PPO Specialty|BCBSTX PPO|||||84.25||| 87046|EAP|0306|CULTURE, STOOL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||84.25||| 87046|EAP|0306|CULTURE, STOOL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||84.25||| 87046|EAP|0300|STOOL ADDL PATHOGENS|Managed Medicaid|MEDICAID AMERIGROUP|||||84.25||| 87046|EAP|0306|CULTURE, STOOL|Aenta Medicare Advantage|AETNA MEDICARE MA|361.25||||361.25||| 87046|EAP|0306|CULTURE, STOOL|Cigna|CIGNA|361.25||||84.25||| 87046|EAP|0306|CULTURE, STOOL|NON CONTRACTED|COMMERCIAL OTHER 1|361.25||||84.25||| 87046|EAP|0306|CULTURE, STOOL|Medicare|MEDICARE ACUTE|361.25||||84.25||| 87046|EAP|0306|CULTURE, STOOL|Blue Cross HMO Specialty|BCBSTX HMO|361.25||||||| 87046|EAP|0306|CULTURE, STOOL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|361.25||||84.25||| 87046|EAP|0306|CULTURE, STOOL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|361.25||||||| 87046|EAP|0306|CULTURE, STOOL|Medicaid|MEDICAID HMO|||||84.25||| 87046|EAP|0306|CULTURE, STOOL|United Healthcare|UNITED HEALTHCARE|||||84.25||| 87046|EAP|0306|CULTURE, STOOL|Medicaid|SUPERIOR HEALTHPLAN CHIP|361.25||||84.25||| 87046|EAP|0306|CULTURE, STOOL|Blue Cross PPO Specialty|BCBSTX OTHER|||||84.25||| 87070|EAP|0300|CULTURE,WOUND|Humana Medicare Advantage|HUMANA MA|3.30||||3.30||| 87070|EAP|0300|CULTURE,WOUND|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.30||||3.30||| 87070|EAP|0300|CULTURE,RESPIRATORY|Humana Medicare Advantage|HUMANA MA|170.50||||3.30||| 87070|EAP|0300|CULTURE,RESPIRATORY|Managed Medicaid|MEDICAID SUPERIOR|3.30||||3.30||| 87070|EAP|0306|CULTURE THROAT/NOSE|Medicare|MEDICARE ACUTE|||||0.77||| 87070|EAP|0306|CULTURE THROAT/NOSE|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.77||| 87070|EAP|0300|CULTURE,RESPIRATORY|Rusk State Hospital|RUSK STATE HOSP|3.30||||3.30||| 87070|EAP|0300|CULTURE,BODY FLUID|Medicaid|MEDICAID|3.30||||170.50||| 87070|EAP|0300|CULTURE,WOUND|Managed Medicaid|MEDICAID AMERIGROUP|170.50||||3.30||| 87070|EAP|0300|CULTURE,BODY FLUID|Blue Cross PPO Specialty|BCBSTX PPO|3.30||||170.50||| 87070|EAP|0300|CULTURE,WOUND|United Healthcare|UNITED HEALTHCARE|3.30||||3.30||| 87070|EAP|0300|CULTURE,RESPIRATORY|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||3.30||| 87070|EAP|0300|CULTURE,RESPIRATORY|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.30||||||| 87070|EAP|0300|CULTURE,BODY FLUID|Medicare|MEDICARE ACUTE|170.50||||170.50||| 87070|EAP|0300|CULTURE,WOUND|Managed Medicaid|MEDICAID SUPERIOR|3.30||||3.30||| 87070|EAP|0300|CULTURE,WOUND|Medicare|MEDICARE ACUTE|3.30||||3.30||| 87070|EAP|0300|CULTURE,RESPIRATORY|Tricare|TRICARE EAST REGION|||||3.30||| 87070|EAP|0300|CULTURE MRSA|Blue Cross PPO Specialty|BCBSTX PPO|170.50||||0.71||| 87070|EAP|0300|CULTURE,WOUND|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.30||||3.30||| 87070|EAP|0300|CULTURE,WOUND|United Medicare Advantage|AARP UHC WEST COMPLETE MA|3.30||||3.30||| 87070|EAP|0300|CULTURE,RESPIRATORY|Medicare|MEDICARE ACUTE|3.30||||3.30||| 87070|EAP|0300|CULTURE MRSA|Workers Compensation|WORKERS COMPENSATION OTHER|3.30||||0.71||| 87070|EAP|0300|CULTURE,RESPIRATORY|Workers Compensation|UT EMPLOYEE INJURY|3.30||||||| 87070|EAP|0300|CULTURE,BODY FLUID|Blue Cross PPO Specialty|BCBSTX OTHER|170.50||||||| 87070|EAP|0300|CULTURE, GENITAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|170.50||||0.77||| 87070|EAP|0300|CULTURE,RESPIRATORY|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.30||||3.30||| 87070|EAP|0300|CULTURE,WOUND|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|170.50||||3.30||| 87070|EAP|0300|CULTURE,WOUND|United Healthcare|UNITED HEALTHCARE|||||3.30||| 87070|EAP|0300|CULTURE, GENITAL|Medicaid|MEDICAID|170.50||||0.77||| 87070|EAP|0300|CULTURE,RESPIRATORY|Managed Medicaid|MEDICAID AMERIGROUP|170.50||||3.30||| 87070|EAP|0306|CULTURE THROAT/NOSE|Aetna|AETNA OTHER|||||0.77||| 87070|EAP|0300|CULTURE,WOUND|Medicaid|MEDICAID|3.30||||3.30||| 87070|EAP|0300|CULTURE,BODY FLUID|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.30||||170.50||| 87070|EAP|0300|CULTURE,WOUND|Blue Cross PPO Specialty|BCBSTX PPO|3.30||||3.30||| 87070|EAP|0300|CULTURE,RESPIRATORY|Cigna|CIGNA|||||3.30||| 87070|EAP|0300|CULTURE, GENITAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.30||||0.77||| 87070|EAP|0300|CULTURE,RESPIRATORY|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|3.30||||||| 87070|EAP|0300|CULTURE,RESPIRATORY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||3.30||| 87070|EAP|0300|CULTURE,WOUND|United Healthcare|UNITED HEALTHCARE OTHER|||||3.30||| 87070|EAP|0306|CULTURE THROAT/NOSE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.77||| 87070|EAP|0300|CULTURE,WOUND|Medicaid|MEDICAID HMO|||||3.30||| 87070|EAP|0300|CULTURE,WOUND|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||3.30||| 87070|EAP|0300|CULTURE,RESPIRATORY|United Medicare Advantage|UHC MEDICARE GOLD MA|170.50||||3.30||| 87070|EAP|0300|CULTURE MRSA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.71||| 87070|EAP|0300|CULTURE,RESPIRATORY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.30||||3.30||| 87070|EAP|0300|CULTURE,WOUND|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.30||||3.30||| 87070|EAP|0300|CULTURE,RESPIRATORY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.30||||3.30||| 87070|EAP|0300|CULTURE,WOUND|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.30||||3.30||| 87070|EAP|0300|CULTURE, GENITAL|Managed Medicaid|MEDICAID SUPERIOR|170.50||||0.77||| 87070|EAP|0300|CULTURE,RESPIRATORY|Managed Medicare|HEALTHSPRING MA|3.30||||||| 87070|EAP|0300|CULTURE, GENITAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.77||| 87070|EAP|0300|CULTURE MRSA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|170.50||||0.71||| 87070|EAP|0300|CULTURE MRSA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.30||||0.71||| 87070|EAP|0300|CULTURE,WOUND|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||3.30||| 87070|EAP|0306|CULTURE THROAT/NOSE|Managed Medicaid|MEDICAID SUPERIOR|0.77||||0.77||| 87070|EAP|0306|CULTURE THROAT/NOSE|Blue Cross PPO Specialty|BCBSTX PPO|||||0.77||| 87070|EAP|0300|CULTURE,WOUND|Brinson Benefits|THE HEALTH PLAN SMITH CO|3.30||||||| 87070|EAP|0300|CULTURE, GENITAL|Blue Cross PPO Specialty|BCBSTX PPO|3.30||||0.77||| 87070|EAP|0300|CULTURE,WOUND|United Medicare Advantage|UHC MEDICARE GOLD MA|3.30||||3.30||| 87070|EAP|0300|CULTURE,BODY FLUID|Aenta Medicare Advantage|AETNA MEDICARE MA|170.50||||170.50||| 87070|EAP|0306|CULTURE THROAT/NOSE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.77||| 87070|EAP|0300|CULTURE,WOUND|Aenta Medicare Advantage|AETNA MEDICARE MA|3.30||||3.30||| 87070|EAP|0300|CULTURE,RESPIRATORY|NON CONTRACTED|COMMERCIAL OTHER 1|3.30||||||| 87070|EAP|0300|CULTURE,RESPIRATORY|Medicaid|COUNTY INDIGENT HEALTH OTHER|3.30||||||| 87070|EAP|0306|CULTURE THROAT/NOSE|Managed Medicaid|MEDICAID AMERIGROUP|||||0.77||| 87070|EAP|0300|CULTURE,RESPIRATORY|Veterans Affairs|VETERANS ADMINISTRATION|||||3.30||| 87070|EAP|0306|CULTURE THROAT/NOSE|Humana Medicare Advantage|HUMANA MA|||||0.77||| 87070|EAP|0300|CULTURE,RESPIRATORY|Blue Cross PPO Specialty|BCBSTX PPO|3.30||||3.30||| 87070|EAP|0300|CULTURE,WOUND|Aetna|AETNA PPO|3.30||||3.30||| 87070|EAP|0300|CULTURE,RESPIRATORY|Aetna|AETNA OTHER|3.30||||||| 87070|EAP|0300|CULTURE,RESPIRATORY|United Medicare Advantage|AARP UHC WEST COMPLETE MA|3.30||||3.30||| 87070|EAP|0300|CULTURE, GENITAL|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||0.77||| 87070|EAP|0300|CULTURE,RESPIRATORY|Blue Cross HMO Specialty|BCBSTX HMO|170.50||||3.30||| 87070|EAP|0300|CULTURE,RESPIRATORY|Medicaid|MEDICAID TEXAS CHILDRENS|||||3.30||| 87070|EAP|0300|CULTURE,WOUND|Blue Cross HMO Specialty|BCBSTX HMO|3.30||||3.30||| 87070|EAP|0300|CULTURE,WOUND|United Healthcare|TML GROUP BENEFITS|||||3.30||| 87070|EAP|0300|CULTURE,WOUND|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||3.30||| 87075|EAP|0300|ANAEROBIC CULTURE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||84.50||| 87075|EAP|0300|ANAEROBIC CULTURE|Humana Medicare Advantage|HUMANA MA|362.50||||362.50||| 87075|EAP|0300|ANAEROBIC CULTURE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|362.50||||84.50||| 87075|EAP|0300|ANAEROBIC CULTURE|Aenta Medicare Advantage|AETNA MEDICARE MA|362.50||||84.50||| 87075|EAP|0300|ANAEROBIC CULTURE|Aetna|AETNA PPO|362.50||||362.50||| 87075|EAP|0300|ANAEROBIC CULTURE|Medicare|MEDICARE ACUTE|362.50||||223.50||| 87075|EAP|0300|ANAEROBIC CULTURE|Blue Cross HMO Specialty|BCBSTX HMO|362.50||||362.50||| 87075|EAP|0300|ANAEROBIC CULTURE|Managed Medicaid|MEDICAID AMERIGROUP|||||223.50||| 87075|EAP|0300|ANAEROBIC CULTURE|Blue Cross PPO Specialty|BCBSTX PPO|||||223.50||| 87075|EAP|0300|ANAEROBIC CULTURE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|362.50||||223.50||| 87075|EAP|0300|ANAEROBIC CULTURE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||362.50||| 87075|EAP|0300|ANAEROBIC CULTURE|Medicaid|MEDICAID|362.50||||||| 87075|EAP|0300|ANAEROBIC CULTURE|Managed Medicaid|MEDICAID SUPERIOR|||||84.50||| 87075|EAP|0300|ANAEROBIC CULTURE|United Medicare Advantage|UHC MEDICARE GOLD MA|362.50||||||| 87075|EAP|0300|ANAEROBIC CULTURE|United Healthcare|UNITED HEALTHCARE|||||362.50||| 87075|EAP|0300|ANAEROBIC CULTURE|Brinson Benefits|THE HEALTH PLAN SMITH CO|362.50||||||| 87076|EAP|0306|ANAEROBIC ID|Brinson Benefits|THE HEALTH PLAN SMITH CO|3.10||||||| 87076|EAP|0306|ANAEROBIC ID|Blue Cross PPO Specialty|BCBSTX PPO|||||3.10||| 87076|EAP|0306|ANAEROBIC ID|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||3.10||| 87076|EAP|0306|ANAEROBIC ID|Medicare|MEDICARE ACUTE|||||3.10||| 87076|EAP|0306|ANAEROBIC ID|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||3.10||| 87076|EAP|0306|ANAEROBIC ID|Humana Medicare Advantage|HUMANA MA|3.10||||3.10||| 87076|EAP|0306|ANAEROBIC ID|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.10||||||| 87076|EAP|0306|ANAEROBIC ID|United Healthcare|UNITED HEALTHCARE|||||3.10||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||72.25||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|United Healthcare|UMR UNITED MEDICAL RESOURCES|3.10||||72.25||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.10||||72.25||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|United Medicare Advantage|AARP UHC WEST COMPLETE MA|3.10||||72.25||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|United Healthcare|UNITED HEALTHCARE|||||3.10||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|United Healthcare|UNITED HEALTHCARE|3.10||||72.25||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|United Healthcare|TML GROUP BENEFITS|||||72.25||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|United Medicare Advantage|UHC MEDICARE GOLD MA|3.10||||72.25||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Veterans Affairs|VETERANS ADMINISTRATION|3.10||||||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|United Healthcare|UNITED HEALTHCARE OTHER|||||72.25||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||72.25||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Cigna|CIGNA|||||72.25||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Brinson Benefits|THE HEALTH PLAN SMITH CO|3.10||||||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Cigna|CIGNA|3.10||||72.25||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Humana Medicare Advantage|HUMANA MA|3.10||||72.25||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||72.25||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Blue Cross PPO Specialty|BCBSTX PPO|3.10||||72.25||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.10||||72.25||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Aetna|AETNA OTHER|3.10||||3.10||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Blue Cross HMO Specialty|BCBSTX HMO|3.10||||72.25||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Aetna|AETNA PPO|||||72.25||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Medicaid|MEDICAID|3.10||||72.25||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Workers Compensation|WORKERS COMPENSATION OTHER|3.10||||||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.10||||72.25||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Medicaid|MOLINA HEALTHCARE OF TEXAS|3.10||||72.25||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Managed Medicaid|MEDICAID AMERIGROUP|3.10||||72.25||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Managed Medicare|HEALTHSPRING MA|3.10||||||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||72.25||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Medicaid|MEDICAID TEXAS CHILDRENS|||||72.25||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Blue Cross PPO Specialty|BCBSTX OTHER|||||72.25||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Medicaid|MEDICAID HMO|||||72.25||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Aenta Medicare Advantage|AETNA MEDICARE MA|3.10||||72.25||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.10||||72.25||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Medicare|MEDICARE ACUTE|3.10||||72.25||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.10||||72.25||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Tricare|TRICARE EAST REGION|||||72.25||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Managed Medicaid|MEDICAID SUPERIOR|3.10||||72.25||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Rusk State Hospital|RUSK STATE HOSP|||||72.25||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||191.13||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|Managed Medicare|HOSPICE OF EAST TEXAS|||||72.25||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.10||||3.10||| 87077|EAP|0306|CULTURE ORGANISM ID AEROB|NON CONTRACTED|COMMERCIAL OTHER 1|||||72.25||| 87081|EAP|0306|CULTURE BETA STREP GRP A|Blue Cross HMO Specialty|BCBSTX HMO|||||59.25||| 87081|EAP|0306|CULTURE BETA STREP GRP A|Medicaid|MEDICAID HMO|||||59.25||| 87081|EAP|0306|CULTURE BETA STREP GRP A|NON CONTRACTED|COMMERCIAL OTHER 1|||||254.25||| 87081|EAP|0306|CULTURE BETA STREP GRP A|NON CONTRACTED|COMMERCIAL OTHER 2|||||59.25||| 87081|EAP|0300|CULTURE, GC|Managed Medicaid|MEDICAID SUPERIOR|59.25||||59.25||| 87081|EAP|0306|CULTURE BETA STREP GRP A|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||59.25||| 87081|EAP|0306|CULTURE BETA STREP GRP A|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||59.25||| 87081|EAP|0306|CULTURE BETA STREP GRP A|Medicaid|MEDICAID|59.25||||59.25||| 87081|EAP|0306|CULTURE BETA STREP GRP A|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||59.25||| 87081|EAP|0306|CULTURE BETA STREP GRP A|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||59.25||| 87081|EAP|0306|CULTURE BETA STREP GRP A|United Healthcare|UNITED HEALTHCARE OTHER|||||59.25||| 87081|EAP|0306|CULTURE BETA STREP GRP A|Cigna|CIGNA|||||59.25||| 87081|EAP|0306|CULTURE BETA STREP GRP A|Tricare|TRICARE EAST REGION|||||59.25||| 87081|EAP|0306|CULTURE BETA STREP GRP A|Managed Medicaid|MEDICAID SUPERIOR|59.25||||59.25||| 87081|EAP|0306|CULTURE BETA STREP GRP A|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||59.25||| 87081|EAP|0306|CULTURE BETA STREP GRP A|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||59.25||| 87081|EAP|0306|CULTURE BETA STREP GRP A|United Healthcare|UNITED HEALTHCARE|254.25||||59.25||| 87081|EAP|0306|CULTURE BETA STREP GRP A|Managed Medicaid|MEDICAID AMERIGROUP|59.25||||59.25||| 87081|EAP|0306|CULTURE BETA STREP GRP A|Blue Cross PPO Specialty|BCBSTX PPO|254.25||||59.25||| 87086|EAP|0300|CULTURE URINE COL. CT.|United Healthcare|UNITED HEALTHCARE|309.75||||72.25||| 87086|EAP|0300|CULTURE URINE COL. CT.|Blue Cross HMO Specialty|BCBSTX HMO|309.75||||72.25||| 87086|EAP|0300|CULTURE URINE COL. CT.|United Healthcare|UNITED HEALTHCARE OTHER|309.75||||72.25||| 87086|EAP|0300|CULTURE URINE COL. CT.|United Medicare Advantage|UHC MEDICARE GOLD MA|309.75||||72.25||| 87086|EAP|0300|CULTURE URINE COL. CT.|Workers Compensation|WORKERS COMPENSATION OTHER|309.75||||1.91||| 87086|EAP|0300|CULTURE URINE COL. CT.|United Healthcare|UNITED HEALTHCARE|||||1.91||| 87086|EAP|0300|CULTURE URINE COL. CT.|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||72.25||| 87086|EAP|0300|CULTURE URINE COL. CT.|United Medicare Advantage|AARP UHC WEST COMPLETE MA|309.75||||72.25||| 87086|EAP|0300|CULTURE URINE COL. CT.|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|309.75||||72.25||| 87086|EAP|0300|CULTURE URINE COL. CT.|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||72.25||| 87086|EAP|0300|CULTURE URINE COL. CT.|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||72.25||| 87086|EAP|0300|CULTURE URINE COL. CT.|Humana Medicare Advantage|HUMANA MA|309.75||||72.25||| 87086|EAP|0300|CULTURE URINE COL. CT.|Blue Cross PPO Specialty|BCBSTX PPO|309.75||||72.25||| 87086|EAP|0300|CULTURE URINE COL. CT.|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|309.75||||72.25||| 87086|EAP|0300|CULTURE URINE COL. CT.|Cigna|CIGNA|||||72.25||| 87086|EAP|0300|CULTURE URINE COL. CT.|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|309.75||||72.25||| 87086|EAP|0300|CULTURE URINE COL. CT.|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|309.75||||72.25||| 87086|EAP|0300|CULTURE URINE COL. CT.|Aetna|AETNA OTHER|309.75||||309.75||| 87086|EAP|0300|CULTURE URINE COL. CT.|Medicaid|MEDICAID TEXAS CHILDRENS|||||72.25||| 87086|EAP|0300|CULTURE URINE COL. CT.|Managed Medicare|HOSPICE OF EAST TEXAS|309.75||||72.25||| 87086|EAP|0300|CULTURE URINE COL. CT.|Medicaid|MEDICAID HMO|||||72.25||| 87086|EAP|0300|CULTURE URINE COL. CT.|Blue Cross PPO Specialty|BCBSTX OTHER|||||72.25||| 87086|EAP|0300|CULTURE URINE COL. CT.|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|309.75||||72.25||| 87086|EAP|0300|CULTURE URINE COL. CT.|Managed Medicare|HEALTHSPRING MA|309.75||||72.25||| 87086|EAP|0300|CULTURE URINE COL. CT.|Access Direct Platinum|HEALTHFIRST TPA UMR|||||72.25||| 87086|EAP|0300|CULTURE URINE COL. CT.|Aetna|AETNA PPO|309.75||||72.25||| 87086|EAP|0300|CULTURE URINE COL. CT.|Veterans Affairs|VETERANS ADMINISTRATION|309.75||||||| 87086|EAP|0300|CULTURE URINE COL. CT.|Managed Medicaid|MEDICAID AMERIGROUP|309.75||||72.25||| 87086|EAP|0300|CULTURE URINE COL. CT.|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|309.75||||72.25||| 87086|EAP|0300|CULTURE URINE COL. CT.|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|309.75||||72.25||| 87086|EAP|0300|CULTURE URINE COL. CT.|Medicaid|MOLINA HEALTHCARE OF TEXAS|309.75||||72.25||| 87086|EAP|0300|CULTURE URINE COL. CT.|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||72.25||| 87086|EAP|0300|CULTURE URINE COL. CT.|NON CONTRACTED|COMMERCIAL OTHER 2|||||72.25||| 87086|EAP|0300|CULTURE URINE COL. CT.|Medicaid|MEDICAID|309.75||||72.25||| 87086|EAP|0300|CULTURE URINE COL. CT.|Managed Medicaid|MEDICAID SUPERIOR|309.75||||72.25||| 87086|EAP|0300|CULTURE URINE COL. CT.|Managed Medicaid|MEDICAID UNITED HEALTHCARE|309.75||||72.25||| 87086|EAP|0300|CULTURE URINE COL. CT.|Tricare|TRICARE EAST REGION|||||72.25||| 87086|EAP|0300|CULTURE URINE COL. CT.|Medicare|MEDICARE ACUTE|309.75||||72.25||| 87086|EAP|0300|CULTURE URINE COL. CT.|Cigna|CIGNA|309.75||||72.25||| 87086|EAP|0300|CULTURE URINE COL. CT.|Rusk State Hospital|RUSK STATE HOSP|309.75||||72.25||| 87086|EAP|0300|CULTURE URINE COL. CT.|Aenta Medicare Advantage|AETNA MEDICARE MA|309.75||||72.25||| 87086|EAP|0300|CULTURE URINE COL. CT.|UTMB|UTMB CORRECTIONAL MANAGED CARE|309.75||||309.75||| 87086|EAP|0300|CULTURE URINE COL. CT.|NON CONTRACTED|COMMERCIAL OTHER 1|309.75||||72.25||| 87088|EAP|0300|URINE PRESUMPTIVE|Managed Medicaid|MEDICAID AMERIGROUP|299.25||||71.25||| 87088|EAP|0300|URINE PRESUMPTIVE|NON CONTRACTED|COMMERCIAL OTHER 1|||||71.25||| 87088|EAP|0300|URINE PRESUMPTIVE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|299.25||||||| 87088|EAP|0300|URINE PRESUMPTIVE|Medicaid|MEDICAID|||||71.25||| 87088|EAP|0300|URINE PRESUMPTIVE|Managed Medicaid|MEDICAID SUPERIOR|||||71.25||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|Managed Medicare|HEALTHSPRING MA|119,546.51|15645.29|47324.67|6538.24|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|133,308.50|16895.62|47324.67|6538.24|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|Medicaid|MEDICAID|86,844.80|40883.68|47324.67|6538.24|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|Rusk State Hospital|RUSK STATE HOSP|96,580.95|47324.67|47324.67|6538.24|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|Medicare|MEDICARE ACUTE|67,969.40|15356.32|47324.67|6538.24|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|Managed Medicare|HOSPICE OF EAST TEXAS|3,284.63|15360.54|47324.67|6538.24|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|731.43|27245.52|47324.67|6538.24|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|38,992.75|15360.54|47324.67|6538.24|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|Blue Cross HMO Specialty|BCBSTX HMO|54,497.58|6538.24|47324.67|6538.24|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|112,946.53|15332.38|47324.67|6538.24|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|Humana Medicare Advantage|HUMANA MA|82,089.40|15432.26|47324.67|6538.24|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|97,631.65|27245.52|47324.67|6538.24|||| 871|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W MCC|United Medicare Advantage|AARP UHC WEST COMPLETE MA|83,671.53|15645.29|47324.67|6538.24|||| 87102|EAP|0306|CULTURE FUNGUS OTHER SOUR|Medicare|MEDICARE ACUTE|3.22||||||| 87102|EAP|0306|CULTURE FUNGUS OTHER SOUR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.75||| 87102|EAP|0306|CULTURE FUNGUS OTHER SOUR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.22||||||| 87102|EAP|0306|CULTURE FUNGUS OTHER SOUR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.22||||||| 87102|EAP|0306|CULTURE FUNGUS OTHER SOUR|Blue Cross PPO Specialty|BCBSTX OTHER|3.22||||||| 87102|EAP|0306|CULTURE FUNGUS OTHER SOUR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.75||| 87102|EAP|0306|CULTURE FUNGUS OTHER SOUR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.22||||||| 87102|EAP|0306|CULTURE FUNGUS OTHER SOUR|Humana Medicare Advantage|HUMANA MA|3.22||||||| 87102|EAP|0306|CULTURE FUNGUS OTHER SOUR|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.75||| 87102|EAP|0306|CULTURE FUNGUS OTHER SOUR|Medicaid|MEDICAID HMO|||||0.75||| 87110|EAP|0306|CULTURE CHLAMYDIA|Managed Medicaid|MEDICAID SUPERIOR|1.75||||1.75||| 87116|EAP|0306|CULTURE AFB|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.14||||||| 87116|EAP|0306|CULTURE AFB|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|4.14||||||| 87116|EAP|0306|CULTURE AFB|Blue Cross HMO Specialty|BCBSTX HMO|4.14||||||| 87116|EAP|0306|CULTURE AFB|Medicare|MEDICARE ACUTE|4.14||||4.14||| 87116|EAP|0306|CULTURE AFB|Humana Medicare Advantage|HUMANA MA|4.14||||||| 87147|EAP|0300|AGGLUTINATION TYPING 1|Medicaid|MEDICAID|164.75||||||| 87147|EAP|0300|SALMONELLA TYPE|Medicare|MEDICARE ACUTE|0.14||||0.14||| 87147|EAP|0300|AGGLUTINATION TYPING 1|Managed Medicaid|MEDICAID SUPERIOR|||||45.75||| 87177|EAP|0300|O&P SMEAR/CONCENTRATION|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||62.50||| 87177|EAP|0300|O&P SMEAR/CONCENTRATION|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||62.50||| 87177|EAP|0300|O&P SMEAR/CONCENTRATION|Blue Cross PPO Specialty|BCBSTX OTHER|||||62.50||| 87177|EAP|0300|O&P SMEAR/CONCENTRATION|Cigna|CIGNA|||||62.50||| 87177|EAP|0300|O&P SMEAR/CONCENTRATION|Humana Medicare Advantage|HUMANA MA|||||62.50||| 87177|EAP|0300|O&P SMEAR/CONCENTRATION|United Medicare Advantage|UHC MEDICARE GOLD MA|||||62.50||| 87177|EAP|0300|O&P SMEAR/CONCENTRATION|NON CONTRACTED|COMMERCIAL OTHER 1|||||62.50||| 87177|EAP|0300|O&P SMEAR/CONCENTRATION|Managed Medicaid|MEDICAID SUPERIOR|||||62.50||| 87177|EAP|0300|O&P SMEAR/CONCENTRATION|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||62.50||| 87177|EAP|0300|O&P SMEAR/CONCENTRATION|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||62.50||| 87177|EAP|0300|O&P SMEAR/CONCENTRATION|Medicare|MEDICARE ACUTE|||||62.50||| 87177|EAP|0300|O&P SMEAR/CONCENTRATION|Blue Cross PPO Specialty|BCBSTX PPO|||||62.50||| 87177|EAP|0300|O&P SMEAR/CONCENTRATION|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||62.50||| 87177|EAP|0300|O&P SMEAR/CONCENTRATION|United Healthcare|UNITED HEALTHCARE|||||62.50||| 87177|EAP|0300|O&P SMEAR/CONCENTRATION|Managed Medicaid|MEDICAID AMERIGROUP|||||62.50||| 87177|EAP|0300|O&P SMEAR/CONCENTRATION|Medicaid|MEDICAID HMO|||||62.50||| 87184|EAP|0300|ANTIBIOTIC SENSI PLATE 1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|220.25||||||| 87184|EAP|0300|ANTIBIOTIC SENSI PLATE 1|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||220.25||| 87184|EAP|0300|ANTIBIOTIC SENSI PLATE 1|Aenta Medicare Advantage|AETNA MEDICARE MA|220.25||||||| 87184|EAP|0300|ANTIBIOTIC SENSI PLATE 1|Humana Medicare Advantage|HUMANA MA|||||0.61||| 87184|EAP|0300|ANTIBIOTIC SENSI PLATE 1|Blue Cross PPO Specialty|BCBSTX PPO|||||0.61||| 87184|EAP|0300|ANTIBIOTIC SENSI PLATE 2|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||220.25||| 87184|EAP|0300|ANTIBIOTIC SENSI PLATE 1|Managed Medicaid|MEDICAID SUPERIOR|||||0.61||| 87184|EAP|0300|ANTIBIOTIC SENSI PLATE 1|Medicare|MEDICARE ACUTE|220.25||||220.25||| 87184|EAP|0300|ANTIBIOTIC SENSI PLATE 1|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.61||| 87184|EAP|0300|ANTIBIOTIC SENSI PLATE 1|Managed Medicare|HEALTHSPRING MA|220.25||||||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|United Medicare Advantage|UHC MEDICARE GOLD MA|3.31||||77.25||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.31||||77.25||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.31||||3.31||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||77.25||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|United Healthcare|UMR UNITED MEDICAL RESOURCES|3.31||||77.25||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||77.25||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|United Healthcare|TML GROUP BENEFITS|||||77.25||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||77.25||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Cigna|CIGNA|3.31||||77.25||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Humana Medicare Advantage|HUMANA MA|3.31||||77.25||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Veterans Affairs|VETERANS ADMINISTRATION|3.31||||||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Blue Cross PPO Specialty|BCBSTX OTHER|||||77.25||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|United Healthcare|UNITED HEALTHCARE|||||3.31||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.31||||77.25||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Workers Compensation|WORKERS COMPENSATION OTHER|3.31||||||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|United Medicare Advantage|AARP UHC WEST COMPLETE MA|3.31||||77.25||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||77.25||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Brinson Benefits|THE HEALTH PLAN SMITH CO|3.31||||||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||77.25||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Cigna|CIGNA|||||77.25||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Aetna|AETNA OTHER|3.31||||3.31||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Blue Cross PPO Specialty|BCBSTX PPO|3.31||||77.25||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Aenta Medicare Advantage|AETNA MEDICARE MA|3.31||||77.25||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|United Healthcare|UNITED HEALTHCARE|||||204.13||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Medicare|MEDICARE ACUTE|3.31||||77.25||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Tricare|TRICARE EAST REGION|||||77.25||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Blue Cross HMO Specialty|BCBSTX HMO|3.31||||77.25||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|United Healthcare|UNITED HEALTHCARE OTHER|||||77.25||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.31||||77.25||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Managed Medicaid|MEDICAID SUPERIOR|3.31||||77.25||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.31||||77.25||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|NON CONTRACTED|COMMERCIAL OTHER 1|||||77.25||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Rusk State Hospital|RUSK STATE HOSP|||||77.25||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Managed Medicare|HOSPICE OF EAST TEXAS|||||77.25||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Aetna|AETNA PPO|||||77.25||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||77.25||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Managed Medicaid|MEDICAID AMERIGROUP|3.31||||77.25||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Managed Medicare|HEALTHSPRING MA|3.31||||||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||77.25||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Medicaid|MEDICAID|3.31||||77.25||| 87186|EAP|0306|CULTURE SENSITIVITY MCI|Medicaid|MEDICAID TEXAS CHILDRENS|||||77.25||| 872|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC|Humana Medicare Advantage|HUMANA MA|44,413.30|9963.435|10008.51|7177.235|||| 872|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC|Veterans Affairs|VETERANS ADMINISTRATION|38,893.40|10008.51|10008.51|7177.235|||| 872|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC|Medicare|MEDICARE ACUTE|48,963.75|9833.7|10008.51|7177.235|||| 872|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC|United Medicare Advantage|AARP UHC WEST COMPLETE MA|49,856.15|10008.51|10008.51|7177.235|||| 872|DRG||SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC|United Medicare Advantage|UHC MEDICARE GOLD MA|55,726.45|7177.235|10008.51|7177.235|||| 87205|EAP|0306|GRAM STAIN|Aenta Medicare Advantage|AETNA MEDICARE MA|163.25||||38.25||| 87205|EAP|0306|GRAM STAIN|United Medicare Advantage|UHC MEDICARE GOLD MA|163.25||||38.25||| 87205|EAP|0306|GRAM STAIN|United Healthcare|UNITED HEALTHCARE OTHER|||||38.25||| 87205|EAP|0306|GRAM STAIN|Veterans Affairs|VETERANS ADMINISTRATION|||||163.25||| 87205|EAP|0306|GRAM STAIN|United Healthcare|UMR UNITED MEDICAL RESOURCES|163.25||||||| 87205|EAP|0306|GRAM STAIN|United Healthcare|TML GROUP BENEFITS|||||38.25||| 87205|EAP|0306|GRAM STAIN|Workers Compensation|WORKERS COMPENSATION OTHER|163.25||||||| 87205|EAP|0306|GRAM STAIN|United Healthcare|UNITED HEALTHCARE|163.25||||163.25||| 87205|EAP|0306|GRAM STAIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|163.25||||38.25||| 87205|EAP|0306|GRAM STAIN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||38.25||| 87205|EAP|0306|GRAM STAIN|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|163.25||||||| 87205|EAP|0306|GRAM STAIN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||38.25||| 87205|EAP|0306|GRAM STAIN|Blue Cross HMO Specialty|BCBSTX HMO|163.25||||38.25||| 87205|EAP|0306|GRAM STAIN|Workers Compensation|UT EMPLOYEE INJURY|163.25||||||| 87205|EAP|0306|GRAM STAIN|Aetna|AETNA OTHER|163.25||||||| 87205|EAP|0306|GRAM STAIN|Cigna|CIGNA|||||38.25||| 87205|EAP|0306|GRAM STAIN|Blue Cross PPO Specialty|BCBSTX OTHER|163.25||||163.25||| 87205|EAP|0306|GRAM STAIN|United Medicare Advantage|AARP UHC WEST COMPLETE MA|163.25||||38.25||| 87205|EAP|0306|GRAM STAIN|United Healthcare|UNITED HEALTHCARE|||||163.25||| 87205|EAP|0306|GRAM STAIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|163.25||||38.25||| 87205|EAP|0306|GRAM STAIN|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||38.25||| 87205|EAP|0306|GRAM STAIN|Blue Cross PPO Specialty|BCBSTX PPO|163.25||||38.25||| 87205|EAP|0306|GRAM STAIN|Aetna|AETNA PPO|163.25||||163.25||| 87205|EAP|0306|GRAM STAIN|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||38.25||| 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||||38.25||| 87205|EAP|0306|GRAM STAIN|Brinson Benefits|THE HEALTH PLAN SMITH CO|163.25||||||| 87205|EAP|0306|GRAM STAIN|Rusk State Hospital|RUSK STATE HOSP|163.25||||163.25||| 87205|EAP|0306|GRAM STAIN|Tricare|TRICARE EAST REGION|||||38.25||| 87205|EAP|0306|GRAM STAIN|Medicaid|MEDICAID TEXAS CHILDRENS|||||38.25||| 87205|EAP|0306|GRAM STAIN|NON CONTRACTED|COMMERCIAL OTHER 1|163.25||||||| 87205|EAP|0306|GRAM STAIN|UTMB|UTMB CORRECTIONAL MANAGED CARE|163.25||||163.25||| 87205|EAP|0306|GRAM STAIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|163.25||||38.25||| 87205|EAP|0306|GRAM STAIN|Medicaid|MEDICAID HMO|||||38.25||| 87205|EAP|0306|GRAM STAIN|Medicare|MEDICARE ACUTE|163.25||||163.25||| 87205|EAP|0306|GRAM STAIN|Managed Medicaid|MEDICAID AMERIGROUP|163.25||||38.25||| 87205|EAP|0306|GRAM STAIN|Medicaid|COUNTY INDIGENT HEALTH OTHER|163.25||||||| 87205|EAP|0306|GRAM STAIN|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||38.25||| 87205|EAP|0306|GRAM STAIN|Humana Medicare Advantage|HUMANA MA|163.25||||38.25||| 87205|EAP|0306|GRAM STAIN|Managed Medicare|HEALTHSPRING MA|163.25||||||| 87205|EAP|0306|GRAM STAIN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|163.25||||38.25||| 87205|EAP|0306|GRAM STAIN|Medicaid|MEDICAID|163.25||||38.25||| 87206|EAP|0306|ACID FAST DIRECT SMEAR|Humana Medicare Advantage|HUMANA MA|205.50||||||| 87206|EAP|0306|ACID FAST DIRECT SMEAR|Medicare|MEDICARE ACUTE|205.50||||0.48||| 87206|EAP|0306|ACID FAST DIRECT SMEAR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|205.50||||||| 87209|EAP|0300|TRICHROME STAIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||62.50||| 87209|EAP|0300|TRICHROME STAIN|Managed Medicaid|MEDICAID SUPERIOR|||||62.50||| 87209|EAP|0300|TRICHROME STAIN|United Medicare Advantage|UHC MEDICARE GOLD MA|||||62.50||| 87209|EAP|0300|TRICHROME STAIN|Cigna|CIGNA|||||62.50||| 87209|EAP|0300|TRICHROME STAIN|Blue Cross PPO Specialty|BCBSTX OTHER|||||62.50||| 87209|EAP|0300|TRICHROME STAIN|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||62.50||| 87209|EAP|0300|TRICHROME STAIN|United Healthcare|UNITED HEALTHCARE|||||62.50||| 87209|EAP|0300|TRICHROME STAIN|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||62.50||| 87209|EAP|0300|TRICHROME STAIN|Blue Cross PPO Specialty|BCBSTX PPO|||||62.50||| 87209|EAP|0300|TRICHROME STAIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||62.50||| 87209|EAP|0300|TRICHROME STAIN|NON CONTRACTED|COMMERCIAL OTHER 1|||||62.50||| 87209|EAP|0300|TRICHROME STAIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||62.50||| 87209|EAP|0300|TRICHROME STAIN|Humana Medicare Advantage|HUMANA MA|||||62.50||| 87209|EAP|0300|TRICHROME STAIN|Medicare|MEDICARE ACUTE|||||62.50||| 87209|EAP|0300|TRICHROME STAIN|Medicaid|MEDICAID HMO|||||62.50||| 87209|EAP|0300|TRICHROME STAIN|Managed Medicaid|MEDICAID AMERIGROUP|||||62.50||| 87210|EAP|0306|WET MOUNT|United Healthcare|UNITED HEALTHCARE|||||38.25||| 87210|EAP|0306|WET MOUNT|NON CONTRACTED|COMMERCIAL OTHER 1|||||38.25||| 87210|EAP|0306|WET MOUNT|Tricare|TRICARE EAST REGION|||||38.25||| 87210|EAP|0306|WET MOUNT|Medicaid|MEDICAID|||||38.25||| 87210|EAP|0306|WET MOUNT|Managed Medicaid|MEDICAID AMERIGROUP|||||38.25||| 87210|EAP|0306|WET MOUNT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||38.25||| 87210|EAP|0306|WET MOUNT|Managed Medicaid|MEDICAID SUPERIOR|||||38.25||| 87210|EAP|0306|WET MOUNT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||38.25||| 87210|EAP|0306|WET MOUNT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||38.25||| 87210|EAP|0306|WET MOUNT|Blue Cross PPO Specialty|BCBSTX OTHER|||||38.25||| 87210|EAP|0306|WET MOUNT|Cigna|CIGNA|||||38.25||| 87210|EAP|0306|WET MOUNT|Medicare|MEDICARE ACUTE|||||38.25||| 87210|EAP|0306|WET MOUNT|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||38.25||| 87210|EAP|0306|WET MOUNT|Blue Cross HMO Specialty|BCBSTX HMO|||||38.25||| 87210|EAP|0306|WET MOUNT|United Healthcare|UNITED HEALTHCARE OTHER|||||100.75||| 87210|EAP|0306|WET MOUNT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||38.25||| 87210|EAP|0306|WET MOUNT|Blue Cross PPO Specialty|BCBSTX PPO|||||38.25||| 87210|EAP|0306|WET MOUNT|United Healthcare|TML GROUP BENEFITS|||||38.25||| 87210|EAP|0306|WET MOUNT|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||38.25||| 87210|EAP|0306|WET MOUNT|Humana Medicare Advantage|HUMANA MA|||||38.25||| 87210|EAP|0306|WET MOUNT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||38.25||| 87210|EAP|0306|WET MOUNT|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||38.25||| 87210|EAP|0306|WET MOUNT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||38.25||| 87210|EAP|0306|WET MOUNT|United Medicare Advantage|UHC MEDICARE GOLD MA|||||38.25||| 87220|EAP|0306|FUNGAL SMEAR|United Medicare Advantage|UHC MEDICARE GOLD MA|||||38.25||| 87220|EAP|0306|FUNGAL SMEAR|Medicaid|MEDICAID HMO|||||38.25||| 87220|EAP|0306|FUNGAL SMEAR|Humana Medicare Advantage|HUMANA MA|163.25||||||| 87220|EAP|0306|FUNGAL SMEAR|Medicare|MEDICARE ACUTE|163.25||||||| 87252|EAP|0300|CULTURE VIRAL,NON-RESPIRA|Managed Medicaid|MEDICAID AMERIGROUP|||||230.50||| 87252|EAP|0300|CULTURE VIRAL,NON-RESPIRA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||897.25||| 87252|EAP|0300|CULTURE VIRAL,NON-RESPIRA|Medicaid|MEDICAID|897.25||||897.25||| 87255|EAP|0300|CULTURE HERPES W/O TYPING|Managed Medicaid|MEDICAID SUPERIOR|2.06||||2.33||| 87255|EAP|0300|CULTURE HERPES W/O TYPING|Cigna|CIGNA|||||2.33||| 87255|EAP|0300|CULTURE HERPES W/O TYPING|Blue Cross PPO Specialty|BCBSTX PPO|||||2.33||| 87255|EAP|0300|CULTURE HERPES W/O TYPING|Humana Medicare Advantage|HUMANA MA|||||2.33||| 87255|EAP|0300|CULTURE HERPES W/O TYPING|Aetna|AETNA OTHER|||||2.33||| 87255|EAP|0300|CULTURE HERPES W/O TYPING|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.33||| 87255|EAP|0300|CULTURE HERPES W/O TYPING|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2.33||| 87255|EAP|0300|CULTURE HERPES W/O TYPING|United Medicare Advantage|UHC MEDICARE GOLD MA|||||2.33||| 87255|EAP|0300|CULTURE HERPES W/O TYPING|Medicare|MEDICARE ACUTE|||||2.33||| 87255|EAP|0300|CULTURE HERPES W/O TYPING|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||2.33||| 87255|EAP|0300|CULTURE HERPES W/O TYPING|Managed Medicaid|MEDICAID AMERIGROUP|||||2.33||| 87255|EAP|0300|CULTURE HERPES W/O TYPING|Blue Cross HMO Specialty|BCBSTX HMO|||||2.33||| 87255|EAP|0300|CULTURE HERPES W/O TYPING|Medicaid|MEDICAID|||||2.33||| 87324|EAP|0300|C DIFF TOXINS A&B|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.02||| 87324|EAP|0300|C DIFF TOXINS A&B|Managed Medicaid|MEDICAID AMERIGROUP|||||1.02||| 87324|EAP|0300|C DIFF TOXINS A&B|Medicaid|MOLINA HEALTHCARE OF TEXAS|3.39||||||| 87324|EAP|0300|C DIFF TOXINS A&B|Medicaid|MEDICAID|3.39||||||| 87324|EAP|0300|C DIFF TOXINS A&B|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.39||||||| 87324|EAP|0300|C DIFF TOXINS A&B|NON CONTRACTED|COMMERCIAL OTHER 1|3.39||||1.02||| 87324|EAP|0300|C DIFF TOXINS A&B|Managed Medicare|HOSPICE OF EAST TEXAS|||||1.02||| 87324|EAP|0300|C DIFF TOXINS A&B|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.02||| 87324|EAP|0300|C DIFF TOXINS A&B|Medicare|MEDICARE ACUTE|3.39||||1.02||| 87324|EAP|0300|C DIFF TOXINS A&B|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.39||||||| 87324|EAP|0300|C DIFF TOXINS A&B|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1.02||| 87324|EAP|0300|C DIFF TOXINS A&B|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||1.02||| 87324|EAP|0300|C DIFF TOXINS A&B|Brinson Benefits|THE HEALTH PLAN SMITH CO|3.39||||||| 87324|EAP|0300|C DIFF TOXINS A&B|Managed Medicaid|MEDICAID SUPERIOR|3.39||||1.02||| 87324|EAP|0300|C DIFF TOXINS A&B|Medicaid|MEDICAID HMO|||||1.02||| 87324|EAP|0300|C DIFF TOXINS A&B|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.39||||1.02||| 87324|EAP|0300|C DIFF TOXINS A&B|Humana Medicare Advantage|HUMANA MA|3.39||||1.02||| 87324|EAP|0300|C DIFF TOXINS A&B|Cigna|CIGNA|3.39||||||| 87324|EAP|0300|C DIFF TOXINS A&B|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|3.39||||1.02||| 87324|EAP|0300|C DIFF TOXINS A&B|Blue Cross PPO Specialty|BCBSTX PPO|||||1.02||| 87324|EAP|0300|C DIFF TOXINS A&B|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.02||| 87324|EAP|0300|C DIFF TOXINS A&B|Aenta Medicare Advantage|AETNA MEDICARE MA|3.39||||3.39||| 87324|EAP|0300|C DIFF TOXINS A&B|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.02||| 87324|EAP|0300|C DIFF TOXINS A&B|Blue Cross PPO Specialty|BCBSTX OTHER|||||1.02||| 87324|EAP|0300|C DIFF TOXINS A&B|United Healthcare|UNITED HEALTHCARE|||||1.02||| 87324|EAP|0300|C DIFF TOXINS A&B|United Medicare Advantage|AARP UHC WEST COMPLETE MA|3.39||||1.02||| 87324|EAP|0300|C DIFF TOXINS A&B|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||3.39||| 87328|EAP|0300|CRYPTOSPORIDIUM ANTIGEN|Aenta Medicare Advantage|AETNA MEDICARE MA|450.75||||450.75||| 87328|EAP|0300|CRYPTOSPORIDIUM ANTIGEN|Blue Cross HMO Specialty|BCBSTX HMO|450.75||||||| 87328|EAP|0300|CRYPTOSPORIDIUM ANTIGEN|Blue Cross PPO Specialty|BCBSTX PPO|||||107.25||| 87328|EAP|0300|CRYPTOSPORIDIUM ANTIGEN|Humana Medicare Advantage|HUMANA MA|450.75||||107.25||| 87328|EAP|0300|CRYPTOSPORIDIUM ANTIGEN|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|450.75||||||| 87328|EAP|0300|CRYPTOSPORIDIUM ANTIGEN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||450.75||| 87328|EAP|0300|CRYPTOSPORIDIUM ANTIGEN|United Healthcare|UNITED HEALTHCARE|||||107.25||| 87328|EAP|0300|CRYPTOSPORIDIUM ANTIGEN|Cigna|CIGNA|450.75||||||| 87328|EAP|0300|CRYPTOSPORIDIUM ANTIGEN|NON CONTRACTED|COMMERCIAL OTHER 1|450.75||||||| 87328|EAP|0300|CRYPTOSPORIDIUM ANTIGEN|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||107.25||| 87328|EAP|0300|GIARDIA LAMBLIA ANTIGEN|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||107.25||| 87328|EAP|0300|CRYPTOSPORIDIUM ANTIGEN|United Medicare Advantage|UHC MEDICARE GOLD MA|||||107.25||| 87328|EAP|0300|GIARDIA LAMBLIA ANTIGEN|United Medicare Advantage|UHC MEDICARE GOLD MA|||||107.25||| 87328|EAP|0300|CRYPTOSPORIDIUM ANTIGEN|Medicare|MEDICARE ACUTE|450.75||||107.25||| 87328|EAP|0300|CRYPTOSPORIDIUM ANTIGEN|Blue Cross PPO Specialty|BCBSTX OTHER|||||107.25||| 87328|EAP|0300|CRYPTOSPORIDIUM ANTIGEN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|450.75||||107.25||| 87328|EAP|0300|CRYPTOSPORIDIUM ANTIGEN|Managed Medicaid|MEDICAID SUPERIOR|450.75||||107.25||| 87328|EAP|0300|GIARDIA LAMBLIA ANTIGEN|Managed Medicaid|MEDICAID AMERIGROUP|||||107.25||| 87328|EAP|0300|GIARDIA LAMBLIA ANTIGEN|Managed Medicaid|MEDICAID SUPERIOR|450.75||||107.25||| 87328|EAP|0300|CRYPTOSPORIDIUM ANTIGEN|Medicaid|SUPERIOR HEALTHPLAN CHIP|450.75||||107.25||| 87328|EAP|0300|CRYPTOSPORIDIUM ANTIGEN|Medicaid|MOLINA HEALTHCARE OF TEXAS|450.75||||||| 87328|EAP|0300|CRYPTOSPORIDIUM ANTIGEN|Managed Medicaid|MEDICAID AMERIGROUP|||||107.25||| 87328|EAP|0300|CRYPTOSPORIDIUM ANTIGEN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|450.75||||||| 87328|EAP|0300|CRYPTOSPORIDIUM ANTIGEN|Medicaid|MEDICAID HMO|||||107.25||| 87328|EAP|0300|CRYPTOSPORIDIUM ANTIGEN|Medicaid|MEDICAID|450.75||||||| 87328|EAP|0300|CRYPTOSPORIDIUM ANTIGEN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|450.75||||||| 87328|EAP|0300|CRYPTOSPORIDIUM ANTIGEN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||107.25||| 87329|EAP|0300|GIARDIA STOOL SPECIMEN|Medicaid|MOLINA HEALTHCARE OF TEXAS|4.43||||||| 87329|EAP|0300|GIARDIA STOOL SPECIMEN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.43||||105.25||| 87329|EAP|0300|GIARDIA STOOL SPECIMEN|Medicaid|SUPERIOR HEALTHPLAN CHIP|4.43||||105.25||| 87329|EAP|0300|GIARDIA STOOL SPECIMEN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|4.43||||||| 87329|EAP|0300|GIARDIA STOOL SPECIMEN|Managed Medicaid|MEDICAID SUPERIOR|4.43||||105.25||| 87329|EAP|0300|GIARDIA STOOL SPECIMEN|Managed Medicaid|MEDICAID AMERIGROUP|||||105.25||| 87329|EAP|0300|GIARDIA STOOL SPECIMEN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.43||||||| 87329|EAP|0300|GIARDIA STOOL SPECIMEN|Medicaid|MEDICAID HMO|||||105.25||| 87329|EAP|0300|GIARDIA STOOL SPECIMEN|NON CONTRACTED|COMMERCIAL OTHER 1|4.43||||||| 87329|EAP|0300|GIARDIA STOOL SPECIMEN|Medicaid|MEDICAID|4.43||||||| 87329|EAP|0300|GIARDIA STOOL SPECIMEN|Medicare|MEDICARE ACUTE|4.43||||105.25||| 87329|EAP|0300|GIARDIA STOOL SPECIMEN|United Healthcare|UNITED HEALTHCARE|||||105.25||| 87329|EAP|0300|GIARDIA STOOL SPECIMEN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||4.43||| 87329|EAP|0300|GIARDIA STOOL SPECIMEN|United Medicare Advantage|UHC MEDICARE GOLD MA|||||105.25||| 87329|EAP|0300|GIARDIA STOOL SPECIMEN|Blue Cross PPO Specialty|BCBSTX OTHER|||||105.25||| 87329|EAP|0300|GIARDIA STOOL SPECIMEN|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|4.43||||||| 87329|EAP|0300|GIARDIA STOOL SPECIMEN|Humana Medicare Advantage|HUMANA MA|4.43||||105.25||| 87329|EAP|0300|GIARDIA STOOL SPECIMEN|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||105.25||| 87329|EAP|0300|GIARDIA STOOL SPECIMEN|Cigna|CIGNA|4.43||||||| 87329|EAP|0300|GIARDIA STOOL SPECIMEN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||105.25||| 87329|EAP|0300|GIARDIA STOOL SPECIMEN|Aenta Medicare Advantage|AETNA MEDICARE MA|4.43||||4.43||| 87329|EAP|0300|GIARDIA STOOL SPECIMEN|Blue Cross PPO Specialty|BCBSTX PPO|||||105.25||| 87329|EAP|0300|GIARDIA STOOL SPECIMEN|Blue Cross HMO Specialty|BCBSTX HMO|4.43||||||| 87337|EAP|0300|ENTAMOEB HIST GROUP AG IA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.89||| 87337|EAP|0300|ENTAMOEB HIST GROUP AG IA|Aenta Medicare Advantage|AETNA MEDICARE MA|2.96||||2.96||| 87337|EAP|0300|ENTAMOEB HIST GROUP AG IA|Blue Cross HMO Specialty|BCBSTX HMO|2.96||||||| 87337|EAP|0300|ENTAMOEB HIST GROUP AG IA|Humana Medicare Advantage|HUMANA MA|2.96||||0.89||| 87337|EAP|0300|ENTAMOEB HIST GROUP AG IA|Cigna|CIGNA|2.96||||||| 87337|EAP|0300|ENTAMOEB HIST GROUP AG IA|NON CONTRACTED|COMMERCIAL OTHER 1|2.96||||||| 87337|EAP|0300|ENTAMOEB HIST GROUP AG IA|Blue Cross PPO Specialty|BCBSTX PPO|||||0.89||| 87337|EAP|0300|ENTAMOEB HIST GROUP AG IA|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.89||| 87337|EAP|0300|ENTAMOEB HIST GROUP AG IA|United Healthcare|UNITED HEALTHCARE|||||0.89||| 87337|EAP|0300|ENTAMOEB HIST GROUP AG IA|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.89||| 87337|EAP|0300|ENTAMOEB HIST GROUP AG IA|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.96||||||| 87337|EAP|0300|ENTAMOEB HIST GROUP AG IA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2.96||| 87337|EAP|0300|ENTAMOEB HIST GROUP AG IA|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||0.89||| 87337|EAP|0300|ENTAMOEB HIST GROUP AG IA|Medicare|MEDICARE ACUTE|2.96||||0.89||| 87337|EAP|0300|ENTAMOEB HIST GROUP AG IA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.96||||0.89||| 87337|EAP|0300|ENTAMOEB HIST GROUP AG IA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.96||||||| 87337|EAP|0300|ENTAMOEB HIST GROUP AG IA|Managed Medicaid|MEDICAID SUPERIOR|2.96||||0.89||| 87337|EAP|0300|ENTAMOEB HIST GROUP AG IA|Managed Medicaid|MEDICAID AMERIGROUP|||||0.89||| 87337|EAP|0300|ENTAMOEB HIST GROUP AG IA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.96||||||| 87337|EAP|0300|ENTAMOEB HIST GROUP AG IA|Medicaid|SUPERIOR HEALTHPLAN CHIP|2.96||||0.89||| 87337|EAP|0300|ENTAMOEB HIST GROUP AG IA|Medicaid|MOLINA HEALTHCARE OF TEXAS|2.96||||||| 87337|EAP|0300|ENTAMOEB HIST GROUP AG IA|Medicaid|MEDICAID|2.96||||||| 87337|EAP|0300|ENTAMOEB HIST GROUP AG IA|Medicaid|MEDICAID HMO|||||0.89||| 87338|EAP|0300|H.PYLORI ANTIGEN STOOL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||107.25||| 87338|EAP|0300|H.PYLORI ANTIGEN STOOL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|459.75||||107.25||| 87338|EAP|0300|H.PYLORI ANTIGEN STOOL|Medicaid|MEDICAID|||||107.25||| 87338|EAP|0300|H.PYLORI ANTIGEN STOOL|Managed Medicare|HEALTHSPRING MA|||||107.25||| 87338|EAP|0300|H.PYLORI ANTIGEN STOOL|Managed Medicaid|MEDICAID AMERIGROUP|||||107.25||| 87338|EAP|0300|H.PYLORI ANTIGEN STOOL|Managed Medicaid|MEDICAID SUPERIOR|||||107.25||| 87338|EAP|0300|H.PYLORI ANTIGEN STOOL|NON CONTRACTED|COMMERCIAL OTHER 1|||||107.25||| 87338|EAP|0300|H.PYLORI ANTIGEN STOOL|Medicare|MEDICARE ACUTE|459.75||||107.25||| 87338|EAP|0300|H.PYLORI ANTIGEN STOOL|United Healthcare|UNITED HEALTHCARE|459.75||||||| 87338|EAP|0300|H.PYLORI ANTIGEN STOOL|United Healthcare|UNITED HEALTHCARE OTHER|||||107.25||| 87338|EAP|0300|H.PYLORI ANTIGEN STOOL|United Healthcare|TML GROUP BENEFITS|||||107.25||| 87338|EAP|0300|H.PYLORI ANTIGEN STOOL|United Medicare Advantage|UHC MEDICARE GOLD MA|459.75||||107.25||| 87338|EAP|0300|H.PYLORI ANTIGEN STOOL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||107.25||| 87338|EAP|0300|H.PYLORI ANTIGEN STOOL|Veterans Affairs|VETERANS ADMINISTRATION|||||107.25||| 87338|EAP|0300|H.PYLORI ANTIGEN STOOL|Blue Cross PPO Specialty|BCBSTX OTHER|||||107.25||| 87338|EAP|0300|H.PYLORI ANTIGEN STOOL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||107.25||| 87338|EAP|0300|H.PYLORI ANTIGEN STOOL|Humana Medicare Advantage|HUMANA MA|459.75||||107.25||| 87338|EAP|0300|H.PYLORI ANTIGEN STOOL|Blue Cross PPO Specialty|BCBSTX PPO|||||107.25||| 87338|EAP|0300|H.PYLORI ANTIGEN STOOL|Blue Cross HMO Specialty|BCBSTX HMO|||||107.25||| 87338|EAP|0300|H.PYLORI ANTIGEN STOOL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||107.25||| 87338|EAP|0300|H.PYLORI ANTIGEN STOOL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||107.25||| 87338|EAP|0300|H.PYLORI ANTIGEN STOOL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||107.25||| 87338|EAP|0300|H.PYLORI ANTIGEN STOOL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||107.25||| 87338|EAP|0300|H.PYLORI ANTIGEN STOOL|Aenta Medicare Advantage|AETNA MEDICARE MA|||||107.25||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|395.75||||92.25||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Aenta Medicare Advantage|AETNA MEDICARE MA|||||92.25||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Blue Cross HMO Specialty|BCBSTX HMO|395.75||||92.25||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Blue Cross PPO Specialty|BCBSTX PPO|395.75||||92.25||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Access Direct Platinum|HEALTHFIRST TPA UMR|||||92.25||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Humana Medicare Advantage|HUMANA MA|395.75||||92.25||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Blue Cross PPO Specialty|BCBSTX OTHER|||||92.25||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Workers Compensation|WORKERS COMPENSATION OTHER|||||395.75||| 87340|EAP|0302|HEPATITIS B SURFACE AG|United Medicare Advantage|UHC MEDICARE GOLD MA|||||92.25||| 87340|EAP|0302|HEPATITIS B SURFACE AG|United Healthcare|UNITED HEALTHCARE OTHER|395.75||||92.25||| 87340|EAP|0302|HEPATITIS B SURFACE AG|United Healthcare|UNITED HEALTHCARE|395.75||||92.25||| 87340|EAP|0302|HEPATITIS B SURFACE AG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|395.75||||92.25||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|395.75||||92.25||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Aetna|AETNA PPO|||||92.25||| 87340|EAP|0302|HEPATITIS B SURFACE AG|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||92.25||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Cigna|CIGNA|395.75||||92.25||| 87340|EAP|0302|HEPATITIS B SURFACE AG|United Healthcare|TML GROUP BENEFITS|||||92.25||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|395.75||||92.25||| 87340|EAP|0302|HEPATITIS B SURFACE AG|United Medicare Advantage|AARP UHC WEST COMPLETE MA|395.75||||92.25||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|395.75||||92.25||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Medicare|MEDICARE ACUTE|395.75||||92.25||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|395.75||||92.25||| 87340|EAP|0302|HEPATITIS B SURFACE AG|NON CONTRACTED|COMMERCIAL OTHER 1|395.75||||92.25||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Managed Medicaid|MEDICAID SUPERIOR|395.75||||92.25||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Medicaid|MOLINA HEALTHCARE OF TEXAS|395.75||||92.25||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|395.75||||92.25||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Managed Medicaid|MEDICAID AMERIGROUP|395.75||||92.25||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||92.25||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Managed Medicare|HEALTHSPRING MA|||||92.25||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||92.25||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Managed Medicare|BCBS MEDICARE PPO MA|||||92.25||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Medicaid|MEDICAID HMO|||||92.25||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Tricare|TRICARE EAST REGION|395.75||||92.25||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Rusk State Hospital|RUSK STATE HOSP|||||92.25||| 87340|EAP|0302|HEPATITIS B SURFACE AG|NON CONTRACTED|COMMERCIAL OTHER 2|||||92.25||| 87340|EAP|0302|HEPATITIS B SURFACE AG|Medicaid|MEDICAID|395.75||||92.25||| 87350|EAP|0306|HEP BE AG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||101.25||| 87350|EAP|0306|HEP BE AG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||101.25||| 87350|EAP|0306|HEP BE AG|Managed Medicaid|MEDICAID AMERIGROUP|3.94||||101.25||| 87350|EAP|0306|HEP BE AG|Managed Medicare|HEALTHSPRING MA|||||101.25||| 87350|EAP|0306|HEP BE AG|Managed Medicaid|MEDICAID SUPERIOR|||||101.25||| 87350|EAP|0306|HEP BE AG|NON CONTRACTED|COMMERCIAL OTHER 1|||||101.25||| 87350|EAP|0306|HEP BE AG|Medicare|MEDICARE ACUTE|101.25||||101.25||| 87350|EAP|0306|HEP BE AG|United Medicare Advantage|UHC MEDICARE GOLD MA|||||101.25||| 87350|EAP|0306|HEP BE AG|Managed Medicare|BCBS MEDICARE PPO MA|||||101.25||| 87350|EAP|0306|HEP BE AG|Medicaid|MEDICAID|||||101.25||| 87350|EAP|0306|HEP BE AG|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||101.25||| 87350|EAP|0306|HEP BE AG|United Healthcare|UNITED HEALTHCARE|||||101.25||| 87350|EAP|0306|HEP BE AG|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||101.25||| 87350|EAP|0306|HEP BE AG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||101.25||| 87350|EAP|0306|HEP BE AG|Access Direct Platinum|HEALTHFIRST TPA UMR|||||101.25||| 87350|EAP|0306|HEP BE AG|Blue Cross PPO Specialty|BCBSTX OTHER|||||101.25||| 87350|EAP|0306|HEP BE AG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||101.25||| 87350|EAP|0306|HEP BE AG|Blue Cross PPO Specialty|BCBSTX PPO|||||101.25||| 87350|EAP|0306|HEP BE AG|Blue Cross HMO Specialty|BCBSTX HMO|||||101.25||| 87350|EAP|0306|HEP BE AG|United Healthcare|TML GROUP BENEFITS|||||101.25||| 87350|EAP|0306|HEP BE AG|Aenta Medicare Advantage|AETNA MEDICARE MA|||||101.25||| 87350|EAP|0306|HEP BE AG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||101.25||| 87350|EAP|0306|HEP BE AG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||101.25||| 87350|EAP|0306|HEP BE AG|Humana Medicare Advantage|HUMANA MA|||||101.25||| 87350|EAP|0306|HEP BE AG|United Medicare Advantage|AARP UHC WEST COMPLETE MA|3.94||||101.25||| 87425|EAP|0300|ROTAVIRUS ANTIGEN DETECTI|Blue Cross PPO Specialty|BCBSTX OTHER|||||107.25||| 87425|EAP|0300|ROTAVIRUS ANTIGEN DETECTI|Blue Cross PPO Specialty|BCBSTX PPO|||||107.25||| 87425|EAP|0300|ROTAVIRUS ANTIGEN DETECTI|Managed Medicaid|MEDICAID AMERIGROUP|||||107.25||| 87425|EAP|0300|ROTAVIRUS ANTIGEN DETECTI|Medicaid|MEDICAID HMO|||||107.25||| 87425|EAP|0300|ROTAVIRUS ANTIGEN DETECTI|Blue Cross HMO Specialty|BCBSTX HMO|459.75||||||| 87425|EAP|0300|ROTAVIRUS ANTIGEN DETECTI|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||107.25||| 87425|EAP|0300|ROTAVIRUS ANTIGEN DETECTI|Managed Medicaid|MEDICAID SUPERIOR|459.75||||107.25||| 87427|EAP|0300|SHIGA TOXIN|Managed Medicaid|MEDICAID AMERIGROUP|||||107.25||| 87449|EAP|0300|C DIFF GDH ANTIGEN|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||1.02||| 87449|EAP|0300|C DIFF GDH ANTIGEN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.39||||1.02||| 87449|EAP|0300|C DIFF GDH ANTIGEN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|178.25||||3.39||| 87449|EAP|0300|C DIFF GDH ANTIGEN|United Medicare Advantage|UHC MEDICARE GOLD MA|178.25||||1.02||| 87449|EAP|0300|C DIFF GDH ANTIGEN|Brinson Benefits|THE HEALTH PLAN SMITH CO|3.39||||||| 87449|EAP|0300|C DIFF GDH ANTIGEN|Blue Cross PPO Specialty|BCBSTX OTHER|||||1.02||| 87449|EAP|0300|C DIFF GDH ANTIGEN|Humana Medicare Advantage|HUMANA MA|3.39||||1.02||| 87449|EAP|0300|C DIFF GDH ANTIGEN|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|3.39||||1.02||| 87449|EAP|0300|C DIFF GDH ANTIGEN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.02||| 87449|EAP|0300|C DIFF GDH ANTIGEN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.02||| 87449|EAP|0300|LEGIONELLA ANTIGEN URINE|Aenta Medicare Advantage|AETNA MEDICARE MA|178.25||||3.39||| 87449|EAP|0300|C DIFF GDH ANTIGEN|Blue Cross PPO Specialty|BCBSTX PPO|178.25||||1.02||| 87449|EAP|0300|LEGIONELLA ANTIGEN URINE|Medicare|MEDICARE ACUTE|178.25||||1.02||| 87449|EAP|0300|LEGIONELLA ANTIGEN URINE|NON CONTRACTED|COMMERCIAL OTHER 1|178.25||||1.02||| 87449|EAP|0300|C DIFF GDH ANTIGEN|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.39||||||| 87449|EAP|0300|C DIFF GDH ANTIGEN|Cigna|CIGNA|3.39||||||| 87449|EAP|0300|C DIFF GDH ANTIGEN|Aenta Medicare Advantage|AETNA MEDICARE MA|3.39||||3.39||| 87449|EAP|0300|C DIFF GDH ANTIGEN|NON CONTRACTED|COMMERCIAL OTHER 1|3.39||||1.02||| 87449|EAP|0300|C DIFF GDH ANTIGEN|Medicare|MEDICARE ACUTE|3.39||||1.02||| 87449|EAP|0300|C DIFF GDH ANTIGEN|Managed Medicaid|MEDICAID SUPERIOR|3.39||||1.02||| 87449|EAP|0300|C DIFF GDH ANTIGEN|United Medicare Advantage|AARP UHC WEST COMPLETE MA|3.39||||1.02||| 87449|EAP|0300|LEGIONELLA ANTIGEN URINE|Humana Medicare Advantage|HUMANA MA|178.25||||1.02||| 87449|EAP|0300|C DIFF GDH ANTIGEN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.39||||||| 87449|EAP|0300|C DIFF GDH ANTIGEN|Managed Medicare|HOSPICE OF EAST TEXAS|||||1.02||| 87449|EAP|0300|LEGIONELLA ANTIGEN URINE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|178.25||||1.02||| 87449|EAP|0300|C DIFF GDH ANTIGEN|United Healthcare|UNITED HEALTHCARE|||||1.02||| 87449|EAP|0300|LEGIONELLA ANTIGEN URINE|Managed Medicaid|MEDICAID SUPERIOR|178.25||||1.02||| 87449|EAP|0300|C DIFF GDH ANTIGEN|Managed Medicaid|MEDICAID AMERIGROUP|||||1.02||| 87449|EAP|0300|C DIFF GDH ANTIGEN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|178.25||||1.02||| 87449|EAP|0300|C DIFF GDH ANTIGEN|Medicaid|MOLINA HEALTHCARE OF TEXAS|3.39||||||| 87449|EAP|0300|C DIFF GDH ANTIGEN|Medicaid|MEDICAID HMO|||||1.02||| 87449|EAP|0300|C DIFF GDH ANTIGEN|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.02||| 87449|EAP|0300|C DIFF GDH ANTIGEN|Medicaid|MEDICAID|3.39||||||| 87491|EAP|0306|CHLAMYDIA AMPLIFIED PROBE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||13.19||| 87491|EAP|0306|CHLAMYDIA AMPLIFIED PROBE|Managed Medicaid|MEDICAID SUPERIOR|||||313.75||| 87491|EAP|0306|CHLAMYDIA AMPLIFIED PROBE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||313.75||| 87491|EAP|0300|CHLAMYDIA BY TMA|Managed Medicaid|MEDICAID AMERIGROUP|1,315.25||||313.75||| 87491|EAP|0300|CHLAMYDIA BY TMA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||313.75||| 87491|EAP|0300|CHLAMYDIA BY TMA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||313.75||| 87491|EAP|0300|CHLAMYDIA BY TMA|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||313.75||| 87491|EAP|0300|CHLAMYDIA BY TMA|Medicaid|MEDICAID HMO|||||313.75||| 87491|EAP|0300|CHLAMYDIA BY TMA|Medicaid|MEDICAID PCCM|||||313.75||| 87491|EAP|0300|CHLAMYDIA BY TMA|Managed Medicaid|MEDICAID SUPERIOR|1,315.25||||313.75||| 87491|EAP|0300|CHLAMYDIA BY TMA|Medicaid|MEDICAID|||||313.75||| 87491|EAP|0300|CHLAMYDIA BY TMA|Tricare|TRICARE EAST REGION|||||313.75||| 87491|EAP|0306|CHLAMYDIA AMPLIFIED PROBE|NON CONTRACTED|COMMERCIAL OTHER 1|||||313.75||| 87491|EAP|0300|CHLAMYDIA BY TMA|NON CONTRACTED|COMMERCIAL OTHER 1|||||313.75||| 87491|EAP|0300|CHLAMYDIA BY TMA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||313.75||| 87491|EAP|0300|CHLAMYDIA BY TMA|Medicare|MEDICARE ACUTE|||||313.75||| 87491|EAP|0300|CHLAMYDIA BY TMA|NON CONTRACTED|COMMERCIAL OTHER 2|||||313.75||| 87491|EAP|0300|CHLAMYDIA BY TMA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||313.75||| 87491|EAP|0306|CHLAMYDIA AMPLIFIED PROBE|Medicaid|MEDICAID|||||313.75||| 87491|EAP|0300|CHLAMYDIA BY TMA|Blue Cross HMO Specialty|BCBSTX HMO|||||313.75||| 87491|EAP|0300|CHLAMYDIA BY TMA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||313.75||| 87491|EAP|0300|CHLAMYDIA BY TMA|Access Direct Platinum|HEALTHFIRST TPA UMR|||||313.75||| 87491|EAP|0306|CHLAMYDIA AMPLIFIED PROBE|Medicare|MEDICARE ACUTE|||||313.75||| 87491|EAP|0306|CHLAMYDIA AMPLIFIED PROBE|Blue Cross HMO Specialty|BCBSTX HMO|||||313.75||| 87491|EAP|0306|CHLAMYDIA AMPLIFIED PROBE|Aetna|AETNA PPO|||||313.75||| 87491|EAP|0300|CHLAMYDIA BY TMA|Aetna|AETNA PPO|||||313.75||| 87491|EAP|0306|CHLAMYDIA AMPLIFIED PROBE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||313.75||| 87491|EAP|0306|CHLAMYDIA AMPLIFIED PROBE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||313.75||| 87491|EAP|0300|CHLAMYDIA BY TMA|Cigna|CIGNA|||||313.75||| 87491|EAP|0306|CHLAMYDIA AMPLIFIED PROBE|Humana Medicare Advantage|HUMANA MA|||||313.75||| 87491|EAP|0300|CHLAMYDIA BY TMA|Blue Cross PPO Specialty|BCBSTX OTHER|||||313.75||| 87491|EAP|0306|CHLAMYDIA AMPLIFIED PROBE|Managed Medicaid|MEDICAID AMERIGROUP|||||313.75||| 87491|EAP|0300|CHLAMYDIA BY TMA|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||313.75||| 87491|EAP|0300|CHLAMYDIA BY TMA|Humana Medicare Advantage|HUMANA MA|||||313.75||| 87491|EAP|0306|CHLAMYDIA AMPLIFIED PROBE|Blue Cross PPO Specialty|BCBSTX OTHER|||||313.75||| 87491|EAP|0300|CHLAMYDIA BY TMA|Blue Cross PPO Specialty|BCBSTX PPO|||||313.75||| 87491|EAP|0306|CHLAMYDIA AMPLIFIED PROBE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||816.38||| 87491|EAP|0306|CHLAMYDIA AMPLIFIED PROBE|Cigna|CIGNA|||||313.75||| 87491|EAP|0300|CHLAMYDIA BY TMA|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||313.75||| 87491|EAP|0300|CHLAMYDIA BY TMA|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||313.75||| 87491|EAP|0306|CHLAMYDIA AMPLIFIED PROBE|Blue Cross PPO Specialty|BCBSTX PPO|||||313.75||| 87491|EAP|0300|CHLAMYDIA BY TMA|United Healthcare|GOLDEN RULE|||||313.75||| 87491|EAP|0300|CHLAMYDIA BY TMA|United Healthcare|UNITED HEALTHCARE|||||313.75||| 87491|EAP|0306|CHLAMYDIA AMPLIFIED PROBE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||313.75||| 87491|EAP|0300|CHLAMYDIA BY TMA|United Healthcare|UNITED HEALTHCARE OTHER|||||313.75||| 87491|EAP|0300|CHLAMYDIA BY TMA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||313.75||| 87491|EAP|0300|CHLAMYDIA BY TMA|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||313.75||| 87491|EAP|0300|CHLAMYDIA BY TMA|United Medicare Advantage|UHC MEDICARE GOLD MA|||||313.75||| 87491|EAP|0306|CHLAMYDIA AMPLIFIED PROBE|United Healthcare|UNITED HEALTHCARE OTHER|||||313.75||| 87493|EAP|0300|C.DIFF TOXIN BY PCR|Humana Medicare Advantage|HUMANA MA|993.25||||||| 87493|EAP|0300|C.DIFF TOXIN BY PCR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|993.25||||||| 87493|EAP|0300|C.DIFF TOXIN BY PCR|Medicare|MEDICARE ACUTE|993.25||||298.50||| 87493|EAP|0300|C.DIFF TOXIN BY PCR|NON CONTRACTED|COMMERCIAL OTHER 1|||||298.50||| 87493|EAP|0300|C.DIFF TOXIN BY PCR|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||298.50||| 87493|EAP|0300|C.DIFF TOXIN BY PCR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||298.50||| 87493|EAP|0300|C.DIFF TOXIN BY PCR|Managed Medicaid|MEDICAID AMERIGROUP|||||298.50||| 87493|EAP|0300|C.DIFF TOXIN BY PCR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||298.50||| 87493|EAP|0300|C.DIFF TOXIN BY PCR|Medicaid|MEDICAID HMO|||||298.50||| 87497|EAP|0300|CYTOMEGALO VIRUS,PCR QT|Medicaid|MEDICAID TEXAS CHILDRENS|||||253.50||| 87497|EAP|0300|CYTOMEGALO VIRUS,PCR QT|Managed Medicaid|MEDICAID SUPERIOR|||||253.50||| 87497|EAP|0300|CYTOMEGALO VIRUS,PCR QT|Medicare|MEDICARE ACUTE|||||253.50||| 87497|EAP|0300|CYTOMEGALO VIRUS,PCR QT|Tricare|TRICARE EAST REGION|||||253.50||| 87497|EAP|0300|CYTOMEGALO VIRUS,PCR QT|Cigna|CIGNA|||||253.50||| 87502|EAP|0300|FLU A/B AG|United Healthcare|UNITED HEALTHCARE OTHER|||||23.35||| 87502|EAP|0300|FLU A/B AG|United Healthcare|UNITED HEALTHCARE|||||23.35||| 87502|EAP|0300|FLU A/B AG|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||23.35||| 87502|EAP|0300|FLU A/B AG|United Healthcare|TML GROUP BENEFITS|||||23.35||| 87502|EAP|0300|FLU A/B AG|United Medicare Advantage|AARP UHC WEST COMPLETE MA|23.35||||23.35||| 87502|EAP|0300|FLU A/B AG|Veterans Affairs|VETERANS ADMINISTRATION|23.35||||23.35||| 87502|EAP|0300|FLU A/B AG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|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|Aetna|AETNA OTHER|||||23.35||| 87502|EAP|0300|FLU A/B AG|Aetna|AETNA PPO|||||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|Blue Cross PPO Specialty|BCBSTX PPO|23.35||||23.35||| 87502|EAP|0300|FLU A/B AG|Cigna|CIGNA|||||23.35||| 87502|EAP|0300|FLU A/B AG|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|23.35||||23.35||| 87502|EAP|0300|FLU A/B AG|Tricare|TRICARE EAST REGION|||||23.35||| 87502|EAP|0300|FLU A/B AG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||23.35||| 87502|EAP|0300|FLU A/B AG|Blue Cross PPO Specialty|BCBSTX OTHER|23.35||||23.35||| 87502|EAP|0300|FLU A/B AG|Rusk State Hospital|RUSK STATE HOSP|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|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||23.35||| 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|Managed Medicaid|MEDICAID SUPERIOR|23.35||||23.35||| 87502|EAP|0300|FLU A/B AG|Managed Medicare|WELLCARE CHOICE MA|||||23.35||| 87502|EAP|0300|FLU A/B AG|Managed Medicare|BCBS MEDICARE PPO MA|||||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|UTMB|UTMB CORRECTIONAL MANAGED CARE|23.35||||23.35||| 87502|EAP|0300|FLU A/B AG|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||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|Managed Medicaid|MEDICAID AMERIGROUP|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|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||23.35||| 87502|EAP|0300|FLU A/B AG|Managed Medicare|HEALTHSPRING MA|||||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|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 PCCM|||||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|Medicaid|MEDICAID HMO|||||23.35||| 87502|EAP|0300|FLU A/B AG|Medicaid|MEDICAID TEXAS CHILDRENS|||||23.35||| 87517|EAP|0306|HEPATITIS B PCR,QUANT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,087.25||| 87517|EAP|0306|HEPATITIS B PCR,QUANT|Blue Cross HMO Specialty|BCBSTX HMO|||||1,087.25||| 87517|EAP|0306|HEPATITIS B PCR,QUANT|Medicare|MEDICARE ACUTE|||||1,087.25||| 87517|EAP|0306|HEPATITIS B PCR,QUANT|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1,087.25||| 87517|EAP|0306|HEPATITIS B PCR,QUANT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1,087.25||| 87517|EAP|0306|HEPATITIS B PCR,QUANT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,087.25||| 87517|EAP|0306|HEPATITIS B PCR,QUANT|NON CONTRACTED|COMMERCIAL OTHER 1|||||1,087.25||| 87522|EAP|0302|HEPATITIS C VIRUS RNA BY|United Medicare Advantage|UHC MEDICARE GOLD MA|||||313.75||| 87522|EAP|0302|HEPATITIS C VIRUS RNA BY|United Medicare Advantage|AARP UHC WEST COMPLETE MA|1,315.25||||313.75||| 87522|EAP|0302|HEPATITIS C VIRUS RNA BY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||814.50||| 87522|EAP|0302|HEPATITIS C VIRUS RNA BY|Humana Medicare Advantage|HUMANA MA|1,315.25||||313.75||| 87522|EAP|0302|HEPATITIS C VIRUS RNA BY|Blue Cross PPO Specialty|BCBSTX PPO|||||1,315.25||| 87522|EAP|0302|HEPATITIS C VIRUS RNA BY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||313.75||| 87522|EAP|0302|HEPATITIS C VIRUS RNA BY|NON CONTRACTED|COMMERCIAL OTHER 1|||||313.75||| 87522|EAP|0302|HEPATITIS C VIRUS RNA BY|Medicare|MEDICARE ACUTE|1,315.25||||313.75||| 87522|EAP|0302|HEPATITIS C VIRUS RNA BY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,315.25||||313.75||| 87522|EAP|0302|HEPATITIS C VIRUS RNA BY|Medicaid|MEDICAID|1,315.25||||313.75||| 87522|EAP|0302|HEPATITIS C VIRUS RNA BY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,315.25||||313.75||| 87529|EAP|0302|HERPES SIMPLEX VIRUS BY P|Medicaid|MEDICAID|||||1,344.75||| 87535|EAP|0300|HIV 1 DNA, PCR, QUAL|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||312.75||| 87536|EAP|0302|HIV 1 RNA, PCR, QUANT|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||760.50||| 87536|EAP|0302|HIV 1 RNA, PCR, QUANT|Medicaid|MEDICAID|||||760.50||| 87536|EAP|0302|HIV 1 RNA, PCR, QUANT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||760.50||| 87591|EAP|0300|GC BY TMA|NON CONTRACTED|COMMERCIAL OTHER 2|||||313.75||| 87591|EAP|0306|NEISSERIA GONORRHOEAE AMP|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||313.75||| 87591|EAP|0306|NEISSERIA GONORRHOEAE AMP|NON CONTRACTED|COMMERCIAL OTHER 1|||||313.75||| 87591|EAP|0306|NEISSERIA GONORRHOEAE AMP|Medicaid|MEDICAID|||||313.75||| 87591|EAP|0300|GC BY TMA|Tricare|TRICARE EAST REGION|||||313.75||| 87591|EAP|0306|NEISSERIA GONORRHOEAE AMP|Medicare|MEDICARE ACUTE|||||313.75||| 87591|EAP|0300|GC BY TMA|Managed Medicaid|MEDICAID AMERIGROUP|1,315.25||||313.75||| 87591|EAP|0306|NEISSERIA GONORRHOEAE AMP|Managed Medicaid|MEDICAID SUPERIOR|||||313.75||| 87591|EAP|0306|NEISSERIA GONORRHOEAE AMP|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||313.75||| 87591|EAP|0300|GC BY TMA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||313.75||| 87591|EAP|0300|GC BY TMA|Managed Medicaid|MEDICAID SUPERIOR|1,315.25||||313.75||| 87591|EAP|0300|GC BY TMA|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||313.75||| 87591|EAP|0300|GC BY TMA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||313.75||| 87591|EAP|0300|GC BY TMA|Medicaid|MEDICAID PCCM|||||313.75||| 87591|EAP|0300|GC BY TMA|Access Direct Platinum|HEALTHFIRST TPA UMR|||||313.75||| 87591|EAP|0300|GC BY TMA|Medicaid|MEDICAID|||||313.75||| 87591|EAP|0300|GC BY TMA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||313.75||| 87591|EAP|0300|GC BY TMA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||313.75||| 87591|EAP|0306|NEISSERIA GONORRHOEAE AMP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||13.19||| 87591|EAP|0300|GC BY TMA|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||313.75||| 87591|EAP|0300|GC BY TMA|NON CONTRACTED|COMMERCIAL OTHER 1|||||313.75||| 87591|EAP|0300|GC BY TMA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||313.75||| 87591|EAP|0306|NEISSERIA GONORRHOEAE AMP|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||313.75||| 87591|EAP|0300|GC BY TMA|Blue Cross HMO Specialty|BCBSTX HMO|||||313.75||| 87591|EAP|0306|NEISSERIA GONORRHOEAE AMP|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||816.38||| 87591|EAP|0306|NEISSERIA GONORRHOEAE AMP|Managed Medicaid|MEDICAID AMERIGROUP|||||313.75||| 87591|EAP|0306|NEISSERIA GONORRHOEAE AMP|Blue Cross HMO Specialty|BCBSTX HMO|||||313.75||| 87591|EAP|0306|NEISSERIA GONORRHOEAE AMP|Aetna|AETNA PPO|||||313.75||| 87591|EAP|0300|GC BY TMA|Medicaid|MEDICAID HMO|||||313.75||| 87591|EAP|0300|GC/URINE/AMPLIFIED PROBE|Managed Medicaid|MEDICAID SUPERIOR|1,315.25||||313.75||| 87591|EAP|0300|GC BY TMA|Blue Cross PPO Specialty|BCBSTX PPO|||||313.75||| 87591|EAP|0306|NEISSERIA GONORRHOEAE AMP|Cigna|CIGNA|||||313.75||| 87591|EAP|0306|NEISSERIA GONORRHOEAE AMP|Blue Cross PPO Specialty|BCBSTX OTHER|||||313.75||| 87591|EAP|0300|GC/URINE/AMPLIFIED PROBE|Blue Cross PPO Specialty|BCBSTX PPO|||||313.75||| 87591|EAP|0306|NEISSERIA GONORRHOEAE AMP|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||313.75||| 87591|EAP|0306|NEISSERIA GONORRHOEAE AMP|Humana Medicare Advantage|HUMANA MA|||||313.75||| 87591|EAP|0300|GC BY TMA|Blue Cross PPO Specialty|BCBSTX OTHER|||||313.75||| 87591|EAP|0300|GC BY TMA|Humana Medicare Advantage|HUMANA MA|||||313.75||| 87591|EAP|0306|NEISSERIA GONORRHOEAE AMP|Blue Cross PPO Specialty|BCBSTX PPO|||||313.75||| 87591|EAP|0300|GC BY TMA|Medicare|MEDICARE ACUTE|||||313.75||| 87591|EAP|0300|GC BY TMA|Cigna|CIGNA|||||313.75||| 87591|EAP|0300|GC BY TMA|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||313.75||| 87591|EAP|0300|GC BY TMA|United Healthcare|UNITED HEALTHCARE OTHER|||||313.75||| 87591|EAP|0300|GC BY TMA|Aetna|AETNA PPO|||||313.75||| 87591|EAP|0300|GC BY TMA|United Healthcare|GOLDEN RULE|||||313.75||| 87591|EAP|0300|GC BY TMA|United Healthcare|UNITED HEALTHCARE|||||313.75||| 87591|EAP|0300|GC BY TMA|United Medicare Advantage|UHC MEDICARE GOLD MA|||||313.75||| 87591|EAP|0300|GC BY TMA|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||313.75||| 87591|EAP|0300|GC BY TMA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||313.75||| 87591|EAP|0306|NEISSERIA GONORRHOEAE AMP|United Healthcare|UNITED HEALTHCARE OTHER|||||313.75||| 87591|EAP|0300|GC BY TMA|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||313.75||| 87591|EAP|0300|GC/URINE/AMPLIFIED PROBE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,315.25||| 87651|EAP|0300|TRICHOMONAS,URINE,MALE|Blue Cross PPO Specialty|BCBSTX PPO|||||298.50||| 87651|EAP|0300|TRICHOMONAS,URINE,MALE|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||298.50||| 87661|EAP|0300|TRICHOMAS BY TMA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||2.87||| 87798|EAP|0300|TRICHOMONAS,URINE,FEMALE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||298.50||| 87798|EAP|0300|TRICHOMONAS,URINE,FEMALE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||298.50||| 87798|EAP|0300|TRICHOMONAS,URINE,FEMALE|Blue Cross HMO Specialty|BCBSTX HMO|||||298.50||| 87798|EAP|0300|TRICHOMONAS,URINE,FEMALE|Aetna|AETNA PPO|||||298.50||| 87798|EAP|0300|TRICHOMONAS,URINE,FEMALE|Blue Cross PPO Specialty|BCBSTX PPO|||||298.50||| 87798|EAP|0300|TRICHOMONAS,URINE,FEMALE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||298.50||| 87798|EAP|0300|TRICHOMONAS,URINE,FEMALE|Cigna|CIGNA|||||298.50||| 87798|EAP|0300|TRICHOMONAS,URINE,FEMALE|Humana Medicare Advantage|HUMANA MA|||||298.50||| 87798|EAP|0300|TRICHOMONAS,URINE,FEMALE|United Healthcare|UNITED HEALTHCARE OTHER|||||298.50||| 87798|EAP|0300|TRICHOMONAS,URINE,FEMALE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||298.50||| 87798|EAP|0300|TRICHOMONAS,URINE,FEMALE|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||298.50||| 87798|EAP|0306|EPSTEIN BARR VIRUS,CSF,PC|Blue Cross HMO Specialty|BCBSTX HMO|1,315.25||||||| 87798|EAP|0300|TRICHOMONAS,URINE,FEMALE|Blue Cross PPO Specialty|BCBSTX OTHER|||||298.50||| 87798|EAP|0300|TRICHOMONAS,URINE,FEMALE|NON CONTRACTED|COMMERCIAL OTHER 1|||||298.50||| 87798|EAP|0300|TRICHOMONAS,URINE,FEMALE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||298.50||| 87798|EAP|0306|EPSTEIN BARR VIRUS,CSF,PC|Medicaid|MEDICAID|||||313.75||| 87798|EAP|0300|TRICHOMONAS,URINE,FEMALE|Managed Medicaid|MEDICAID SUPERIOR|||||298.50||| 87798|EAP|0300|TRICHOMONAS,URINE,FEMALE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||298.50||| 87798|EAP|0300|TRICHOMONAS,URINE,FEMALE|Managed Medicaid|MEDICAID AMERIGROUP|||||298.50||| 87798|EAP|0300|TRICHOMONAS,URINE,FEMALE|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||298.50||| 87798|EAP|0300|TRICHOMONAS,URINE,FEMALE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||298.50||| 87798|EAP|0300|TRICHOMONAS,URINE,FEMALE|Medicaid|MEDICAID HMO|||||298.50||| 87798|EAP|0300|TRICHOMONAS,URINE,FEMALE|Medicaid|MEDICAID|||||298.50||| 87798|EAP|0306|EPSTEIN BARR VIRUS,CSF,PC|Managed Medicaid|MEDICAID SUPERIOR|1,315.25||||||| 87798|EAP|0300|TRICHOMONAS,URINE,FEMALE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||298.50||| 87798|EAP|0300|TRICHOMONAS,URINE,FEMALE|Tricare|TRICARE EAST REGION|||||298.50||| 87798|EAP|0300|TRICHOMONAS,URINE,FEMALE|Managed Medicare|HEALTHSPRING MA|||||298.50||| 87798|EAP|0300|TRICHOMONAS,URINE,FEMALE|Medicare|MEDICARE ACUTE|||||298.50||| 87799|EAP|0300|EPSTEIN BAR VIRUS PCR QT|Medicaid|MEDICAID TEXAS CHILDRENS|||||382.75||| 87799|EAP|0300|EPSTEIN BAR VIRUS PCR QT|Managed Medicaid|MEDICAID SUPERIOR|||||382.75||| 87799|EAP|0300|BK VIRUS PCR,QNT|Medicaid|MEDICAID TEXAS CHILDRENS|||||382.75||| 87799|EAP|0300|EPSTEIN BAR VIRUS PCR QT|Tricare|TRICARE EAST REGION|||||382.75||| 87799|EAP|0300|EPSTEIN BAR VIRUS PCR QT|Humana Medicare Advantage|HUMANA MA|||||382.75||| 87799|EAP|0300|EPSTEIN BAR VIRUS PCR QT|Medicaid|MEDICAID|||||382.75||| 87799|EAP|0300|BK VIRUS PCR,QNT|Cigna|CIGNA|||||382.75||| 87799|EAP|0300|EPSTEIN BAR VIRUS PCR QT|Blue Cross PPO Specialty|BCBSTX PPO|||||382.75||| 87799|EAP|0300|BK VIRUS PCR,QNT|Medicare|MEDICARE ACUTE|||||382.75||| 87799|EAP|0300|EPSTEIN BAR VIRUS PCR QT|Cigna|CIGNA|||||382.75||| 87799|EAP|0300|EPSTEIN BAR VIRUS PCR QT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||382.75||| 87799|EAP|0300|EPSTEIN BAR VIRUS PCR QT|Blue Cross HMO Specialty|BCBSTX HMO|||||382.75||| 87799|EAP|0300|EPSTEIN BAR VIRUS PCR QT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||382.75||| 87801|EAP|0300|BORDATELLA PERTUSSIS (TEX|Cigna|CIGNA|1,315.25||||313.75||| 87801|EAP|0300|BORDATELLA PERTUSSIS (TEX|Managed Medicaid|MEDICAID SUPERIOR|||||313.75||| 87801|EAP|0300|BORDATELLA PERTUSSIS (TEX|Managed Medicaid|MEDICAID AMERIGROUP|||||313.75||| 87801|EAP|0300|BORDATELLA PERTUSSIS (TEX|Medicaid|MEDICAID|1,315.25||||313.75||| 87801|EAP|0300|BORDATELLA PERTUSSIS (TEX|Medicaid|MEDICAID HMO|||||1,315.25||| 87804|EAP|0300|CLINIC-INFLUENZA A&B|Medicare|MEDICARE ACUTE|||||0.75||| 87804|EAP|0300|CLINIC-INFLUENZA A&B|Medicaid|MEDICAID|||||0.75||| 87804|EAP|0300|CLINIC-INFLUENZA A&B|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.75||| 87804|EAP|0300|CLINIC-INFLUENZA A&B|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.75||| 87804|EAP|0306|FLU A&B SCREEN|Medicare|MEDICARE ACUTE|459.75||||||| 87807|EAP|0302|RESPIRATONY SYNCYTIAL VIR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||459.75||| 87807|EAP|0302|RESPIRATONY SYNCYTIAL VIR|Aetna|AETNA OTHER|||||459.75||| 87807|EAP|0302|RESPIRATONY SYNCYTIAL VIR|Cigna|CIGNA|||||459.75||| 87807|EAP|0302|RESPIRATONY SYNCYTIAL VIR|Blue Cross HMO Specialty|BCBSTX HMO|459.75||||||| 87807|EAP|0302|RESPIRATONY SYNCYTIAL VIR|Blue Cross PPO Specialty|BCBSTX OTHER|||||459.75||| 87807|EAP|0302|RESPIRATONY SYNCYTIAL VIR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||459.75||| 87807|EAP|0302|RESPIRATONY SYNCYTIAL VIR|Managed Medicaid|MEDICAID SUPERIOR|459.75||||459.75||| 87807|EAP|0302|RESPIRATONY SYNCYTIAL VIR|Managed Medicaid|MEDICAID AMERIGROUP|459.75||||459.75||| 87807|EAP|0302|RESPIRATONY SYNCYTIAL VIR|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||459.75||| 87807|EAP|0300|CLINIC-RSV|Managed Medicaid|MEDICAID AMERIGROUP|||||120.75||| 87807|EAP|0302|RESPIRATONY SYNCYTIAL VIR|Medicaid|MEDICAID HMO|||||459.75||| 87807|EAP|0302|RESPIRATONY SYNCYTIAL VIR|Blue Cross PPO Specialty|BCBSTX PPO|459.75||||459.75||| 87807|EAP|0302|RESPIRATONY SYNCYTIAL VIR|Managed Medicare|WELLCARE CHOICE MA|||||459.75||| 87807|EAP|0300|CLINIC-RSV|Medicaid|MEDICAID|120.75||||120.75||| 87807|EAP|0302|RESPIRATONY SYNCYTIAL VIR|Medicaid|MEDICAID TEXAS CHILDRENS|||||459.75||| 87807|EAP|0302|RESPIRATONY SYNCYTIAL VIR|Medicare|MEDICARE ACUTE|459.75||||459.75||| 87807|EAP|0302|RESPIRATONY SYNCYTIAL VIR|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||459.75||| 87807|EAP|0302|RESPIRATONY SYNCYTIAL VIR|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||459.75||| 87807|EAP|0302|RESPIRATONY SYNCYTIAL VIR|Medicaid|MEDICAID|459.75||||459.75||| 87807|EAP|0300|CLINIC-RSV|Managed Medicaid|MEDICAID SUPERIOR|||||120.75||| 87807|EAP|0302|RESPIRATONY SYNCYTIAL VIR|United Healthcare|UNITED HEALTHCARE|||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|NON CONTRACTED|COMMERCIAL OTHER 1|||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Medicaid|MEDICAID PCCM|||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Rusk State Hospital|RUSK STATE HOSP|||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Tricare|TRICARE EAST REGION|||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Medicare|MEDICARE ACUTE|459.75||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Medicaid|MEDICAID HMO|||||459.75||| 87880|EAP|0300|CLINIC-STREP A|Medicare|MEDICARE ACUTE|||||72.25||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Managed Medicare|HEALTHSPRING MA|||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Managed Medicaid|MEDICAID SUPERIOR|459.75||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Managed Medicaid|MEDICAID AMERIGROUP|||||459.75||| 87880|EAP|0300|CLINIC-STREP A|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||72.25||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Medicaid|MEDICAID|459.75||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|459.75||||459.75||| 87880|EAP|0300|CLINIC-STREP A|Medicaid|MEDICAID|||||72.25||| 87880|EAP|0300|CLINIC-STREP A|Managed Medicaid|MEDICAID AMERIGROUP|||||72.25||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|United Medicare Advantage|UHC MEDICARE GOLD MA|||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|United Healthcare|UNITED HEALTHCARE OTHER|||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Medicaid|MEDICAID TEXAS CHILDRENS|||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|United Healthcare|UNITED HEALTHCARE|||||459.75||| 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|United Healthcare|TML GROUP BENEFITS|||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Veterans Affairs|VETERANS ADMINISTRATION|||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|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|United Medicare Advantage|AARP UHC WEST COMPLETE MA|459.75||||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|459.75||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Aetna|AETNA PPO|||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Blue Cross HMO Specialty|BCBSTX HMO|459.75||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Aenta Medicare Advantage|AETNA MEDICARE MA|||||459.75||| 87880|EAP|0306|STREP SCREEN (BETA) RAPID|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||459.75||| 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 PPO Specialty|BCBSTX OTHER|||||459.75||| 87899|EAP|0300|PNEUMOCOCCAL ANTIGEN,URIN|United Medicare Advantage|AARP UHC WEST COMPLETE MA|459.75||||||| 87899|EAP|0300|PNEUMOCOCCAL ANTIGEN,URIN|United Medicare Advantage|UHC MEDICARE GOLD MA|459.75||||||| 87899|EAP|0300|PNEUMOCOCCAL ANTIGEN,URIN|Humana Medicare Advantage|HUMANA MA|459.75||||||| 87899|EAP|0300|PNEUMOCOCCAL ANTIGEN,URIN|Managed Medicaid|MEDICAID SUPERIOR|459.75||||||| 87899|EAP|0300|PNEUMOCOCCAL ANTIGEN,URIN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|459.75||||||| 87899|EAP|0300|PNEUMOCOCCAL ANTIGEN,URIN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|459.75||||||| 87899|EAP|0300|PNEUMOCOCCAL ANTIGEN,URIN|Blue Cross PPO Specialty|BCBSTX PPO|459.75||||||| 87899|EAP|0300|PNEUMOCOCCAL ANTIGEN,URIN|Medicare|MEDICARE ACUTE|459.75||||||| 87899|EAP|0300|PNEUMOCOCCAL ANTIGEN,URIN|Aenta Medicare Advantage|AETNA MEDICARE MA|459.75||||||| 87902|EAP|0306|HEPATITIS C VIRAL GENOTYP|NON CONTRACTED|COMMERCIAL OTHER 1|||||253.50||| 87902|EAP|0306|HEPATITIS C VIRAL GENOTYP|Blue Cross PPO Specialty|BCBSTX PPO|||||253.50||| 87999|EAP|0306||Workers Compensation|WORKERS COMPENSATION OTHER|||||72.25||| 88112|EAP|0310|NON-GYN THIN PREP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|906.50||||||| 88112|EAP|0310|NON-GYN THIN PREP|Medicare|MEDICARE ACUTE|906.50||||||| 88112|EAP|0310|NON-GYN THIN PREP|Humana Medicare Advantage|HUMANA MA|906.50||||||| 88112|EAP|0310|NON-GYN THIN PREP|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|906.50||||||| 88112|EAP|0310|NON-GYN THIN PREP|Blue Cross PPO Specialty|BCBSTX PPO|906.50||||906.50||| 88112|EAP|0310|NON-GYN THIN PREP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|906.50||||||| 88112|EAP|0310|NON-GYN THIN PREP|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||215.50||| 88112|EAP|0310|NON-GYN THIN PREP|Managed Medicare|HEALTHSPRING MA|||||215.50||| 88164|EAP|0300|CYTOPATH TBS C/V MANUAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||169.10||| 88173|EAP|0300|FNA INTERPRETAION & REPOR|United Medicare Advantage|UHC MEDICARE GOLD MA|||||215.50||| 88173|EAP|0300|FNA INTERPRETAION & REPOR|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||5.61||| 88173|EAP|0300|FNA INTERPRETAION & REPOR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||215.50||| 88173|EAP|0300|FNA INTERPRETAION & REPOR|Blue Cross PPO Specialty|BCBSTX PPO|||||215.50||| 88173|EAP|0300|FNA INTERPRETAION & REPOR|Medicaid|MEDICAID|||||906.50||| 88187|EAP|0310||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||62.75||| 88300|EAP|0310|LEVEL I (GROSS ONLY)|Humana Medicare Advantage|HUMANA MA|||||1.03||| 88300|EAP|0310|LEVEL I (GROSS ONLY)|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.03||| 88300|EAP|0310|LEVEL I (GROSS ONLY)|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1.03||| 88300|EAP|0310|LEVEL I (GROSS ONLY)|Medicare|MEDICARE ACUTE|||||1.03||| 88300|EAP|0310|LEVEL I (GROSS ONLY)|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||433.25||| 88300|EAP|0310|LEVEL I (GROSS ONLY)|Blue Cross PPO Specialty|BCBSTX PPO|||||433.25||| 88300|EAP|0310|LEVEL I (GROSS ONLY)|Managed Medicaid|MEDICAID SUPERIOR|||||433.25||| 88300|EAP|0310|LEVEL I (GROSS ONLY)|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||433.25||| 88302|EAP|0310|LEVEL II (GROSS & MICRO)|Managed Medicaid|MEDICAID SUPERIOR|433.25||||433.25||| 88302|EAP|0310|LEVEL II (GROSS & MICRO)|Managed Medicaid|MEDICAID AMERIGROUP|433.25||||433.25||| 88302|EAP|0310|LEVEL II (GROSS & MICRO)|Medicare|MEDICARE ACUTE|||||433.25||| 88302|EAP|0310|LEVEL II (GROSS & MICRO)|United Medicare Advantage|UHC MEDICARE GOLD MA|||||433.25||| 88302|EAP|0310|LEVEL II (GROSS & MICRO)|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||433.25||| 88302|EAP|0310|LEVEL II (GROSS & MICRO)|Aenta Medicare Advantage|AETNA MEDICARE MA|||||433.25||| 88302|EAP|0310|LEVEL II (GROSS & MICRO)|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|433.25||||433.25||| 88302|EAP|0310|LEVEL II (GROSS & MICRO)|Humana Medicare Advantage|HUMANA MA|433.25||||433.25||| 88302|EAP|0310|LEVEL II (GROSS & MICRO)|Managed Medicaid|MEDICAID UNITED HEALTHCARE|433.25||||433.25||| 88302|EAP|0310|LEVEL II (GROSS & MICRO)|Blue Cross PPO Specialty|BCBSTX PPO|433.25||||433.25||| 88304|EAP|0310|LEVEL III (GROSS & MICRO)|Managed Medicare|HEALTHSPRING MA|906.50||||||| 88304|EAP|0310|LEVEL III (GROSS & MICRO)|Managed Medicare|BCBS MEDICARE PPO MA|||||906.50||| 88304|EAP|0310|LEVEL III (GROSS & MICRO)|Humana Medicare Advantage|HUMANA MA|906.50||||215.50||| 88304|EAP|0310|LEVEL III (GROSS & MICRO)|Blue Cross PPO Specialty|BCBSTX PPO|906.50||||906.50||| 88304|EAP|0310|LEVEL III (GROSS & MICRO)|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||906.50||| 88304|EAP|0310|LEVEL III (GROSS & MICRO)|Blue Cross HMO Specialty|BCBSTX HMO|||||906.50||| 88304|EAP|0310|LEVEL III (GROSS & MICRO)|United Healthcare|UMR UNITED MEDICAL RESOURCES|906.50||||||| 88304|EAP|0310|LEVEL III (GROSS & MICRO)|United Medicare Advantage|UHC MEDICARE GOLD MA|906.50||||906.50||| 88304|EAP|0310|LEVEL III (GROSS & MICRO)|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||906.50||| 88304|EAP|0310|LEVEL III (GROSS & MICRO)|United Medicare Advantage|AARP UHC WEST COMPLETE MA|906.50||||906.50||| 88304|EAP|0310|LEVEL III (GROSS & MICRO)|Medicare|MEDICARE ACUTE|906.50||||906.50||| 88304|EAP|0310|LEVEL III (GROSS & MICRO)|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||906.50||| 88304|EAP|0310|LEVEL III (GROSS & MICRO)|Managed Medicaid|MEDICAID AMERIGROUP|||||906.50||| 88304|EAP|0310|LEVEL III (GROSS & MICRO)|Managed Medicaid|MEDICAID SUPERIOR|||||906.50||| 88304|EAP|0310|LEVEL III (GROSS & MICRO)|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||906.50||| 88304|EAP|0310|LEVEL III (GROSS & MICRO)|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||906.50||| 88305|EAP|0310|LEVEL IV (GROSS & MICRO)|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||906.50||| 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 CIGNA HEALTHSPRING|906.50||||906.50||| 88305|EAP|0310|LEVEL IV (GROSS & MICRO)|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||906.50||| 88305|EAP|0310|LEVEL IV (GROSS & MICRO)|Managed Medicare|HEALTHSPRING MA|||||906.50||| 88305|EAP|0310|LEVEL IV (GROSS & MICRO)|Managed Medicare|BCBS MEDICARE PPO MA|||||906.50||| 88305|EAP|0310|LEVEL IV (GROSS & MICRO)|Managed Medicaid|MEDICAID AMERIGROUP|906.50||||5.61||| 88305|EAP|0310|LEVEL IV (GROSS & MICRO)|Medicaid|MEDICAID HMO|||||215.50||| 88305|EAP|0310|LEVEL IV (GROSS & MICRO)|Medicare|MEDICARE ACUTE|906.50||||906.50||| 88305|EAP|0310|LEVEL IV (GROSS & MICRO)|Medicaid|MEDICAID|||||906.50||| 88305|EAP|0310|LEVEL IV (GROSS & MICRO)|United Medicare Advantage|UHC MEDICARE GOLD MA|906.50||||215.50||| 88305|EAP|0310|LEVEL IV (GROSS & MICRO)|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|906.50||||||| 88305|EAP|0310|LEVEL IV (GROSS & MICRO)|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|906.50||||906.50||| 88305|EAP|0310|LEVEL IV (GROSS & MICRO)|United Healthcare|UNITED HEALTHCARE OTHER|||||906.50||| 88305|EAP|0310|LEVEL IV (GROSS & MICRO)|United Medicare Advantage|AARP UHC WEST COMPLETE MA|906.50||||906.50||| 88305|EAP|0310|LEVEL IV (GROSS & MICRO)|Aenta Medicare Advantage|AETNA MEDICARE MA|906.50||||906.50||| 88305|EAP|0310|LEVEL IV (GROSS & MICRO)|Blue Cross HMO Specialty|BCBSTX HMO|||||906.50||| 88305|EAP|0310|LEVEL IV (GROSS & MICRO)|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|906.50||||906.50||| 88305|EAP|0310|LEVEL IV (GROSS & MICRO)|Humana Medicare Advantage|HUMANA MA|906.50||||906.50||| 88305|EAP|0310|LEVEL IV (GROSS & MICRO)|Cigna|CIGNA|906.50||||906.50||| 88305|EAP|0310|LEVEL IV (GROSS & MICRO)|Blue Cross PPO Specialty|BCBSTX PPO|906.50||||906.50||| 88307|EAP|0310|LEVEL V (GROSS & MICRO)|Humana Medicare Advantage|HUMANA MA|1,425.25||||1,425.25||| 88307|EAP|0310|LEVEL V (GROSS & MICRO)|Blue Cross PPO Specialty|BCBSTX PPO|1,425.25||||1,425.25||| 88307|EAP|0310|LEVEL V (GROSS & MICRO)|Aenta Medicare Advantage|AETNA MEDICARE MA|1,425.25||||||| 88307|EAP|0310|LEVEL V (GROSS & MICRO)|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,425.25||||1,425.25||| 88307|EAP|0310|LEVEL V (GROSS & MICRO)|Blue Cross HMO Specialty|BCBSTX HMO|||||1,425.25||| 88307|EAP|0310|LEVEL V (GROSS & MICRO)|United Medicare Advantage|AARP UHC WEST COMPLETE MA|1,425.25||||||| 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)|Medicare|MEDICARE ACUTE|1,425.25||||||| 88307|EAP|0310|LEVEL V (GROSS & MICRO)|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,425.25||||1,425.25||| 88307|EAP|0310|LEVEL V (GROSS & MICRO)|Managed Medicaid|MEDICAID SUPERIOR|1,425.25||||||| 88307|EAP|0310|LEVEL V (GROSS & MICRO)|Managed Medicaid|MEDICAID AMERIGROUP|1,425.25||||||| 88309|EAP|0310|LEVEL VI (GROSS & MICRO)|Managed Medicare|HEALTHSPRING MA|1,425.25||||||| 88309|EAP|0310|LEVEL VI (GROSS & MICRO)|Medicaid|MEDICAID|1,425.25||||||| 88309|EAP|0310|LEVEL VI (GROSS & MICRO)|Humana Medicare Advantage|HUMANA MA|1,425.25||||||| 88309|EAP|0310|LEVEL VI (GROSS & MICRO)|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,425.25||||||| 88309|EAP|0310|LEVEL VI (GROSS & MICRO)|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,425.25||||||| 88311|EAP|0310|BONE DECALCIFICATION|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|264.25||||||| 88311|EAP|0310|BONE DECALCIFICATION|Aenta Medicare Advantage|AETNA MEDICARE MA|264.25||||||| 88311|EAP|0310|BONE DECALCIFICATION|Humana Medicare Advantage|HUMANA MA|264.25||||264.25||| 88311|EAP|0310|BONE DECALCIFICATION|Blue Cross PPO Specialty|BCBSTX PPO|264.25||||||| 88311|EAP|0310|BONE DECALCIFICATION|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|264.25||||||| 88311|EAP|0310|BONE DECALCIFICATION|United Medicare Advantage|UHC MEDICARE GOLD MA|264.25||||||| 88311|EAP|0310|BONE DECALCIFICATION|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|264.25||||||| 88311|EAP|0310|BONE DECALCIFICATION|United Medicare Advantage|AARP UHC WEST COMPLETE MA|264.25||||||| 88311|EAP|0310|BONE DECALCIFICATION|Medicare|MEDICARE ACUTE|264.25||||264.25||| 88311|EAP|0310|BONE DECALCIFICATION|Managed Medicaid|MEDICAID SUPERIOR|264.25||||||| 88311|EAP|0310|BONE DECALCIFICATION|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|264.25||||||| 88312|EAP|0310|SPECIAL STAINS GROUP I|Humana Medicare Advantage|HUMANA MA|433.25||||1.03||| 88312|EAP|0310|SPECIAL STAINS GROUP I|Medicare|MEDICARE ACUTE|433.25||||433.25||| 88313|EAP|0300|OVA & PARASITES|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1.03||| 88313|EAP|0300|OVA & PARASITES|Humana Medicare Advantage|HUMANA MA|||||1.03||| 88313|EAP|0310|SPECIAL STAINS GROUP II(I|Medicare|MEDICARE ACUTE|433.25||||433.25||| 88342|EAP|0310|IMMUNOHISTOCHEMISTRY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||906.50||| 88342|EAP|0310|IMMUNOHISTOCHEMISTRY|Medicaid|MEDICAID|906.50||||||| 88342|EAP|0310|IMMUNOHISTOCHEMISTRY|Medicare|MEDICARE ACUTE|906.50||||906.50||| 88342|EAP|0310|IMMUNOHISTOCHEMISTRY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||906.50||| 88342|EAP|0310|IMMUNOHISTOCHEMISTRY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||906.50||| 88342|EAP|0310|IMMUNOHISTOCHEMISTRY|Blue Cross HMO Specialty|BCBSTX HMO|||||906.50||| 88342|EAP|0310|IMMUNOHISTOCHEMISTRY|Humana Medicare Advantage|HUMANA MA|906.50||||906.50||| 88342|EAP|0310|IMMUNOHISTOCHEMISTRY|Blue Cross PPO Specialty|BCBSTX PPO|||||906.50||| 88342|EAP|0310|IMMUNOHISTOCHEMISTRY|Cigna|CIGNA|||||906.50||| 88342|EAP|0310|IMMUNOHISTOCHEMISTRY|United Medicare Advantage|UHC MEDICARE GOLD MA|||||906.50||| 88342|EAP|0310|IMMUNOHISTOCHEMISTRY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||906.50||| 88342|EAP|0310|IMMUNOHISTOCHEMISTRY|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||906.50||| 88342|EAP|0310|IMMUNOHISTOCHEMISTRY|United Healthcare|UNITED HEALTHCARE OTHER|||||906.50||| 89050|EAP|0309|SMEAR, EOSINOPHILS, NON N|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.82||||||| 89050|EAP|0309|SMEAR, EOSINOPHILS, NON N|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.82||||||| 89051|EAP|0300|BODY FLUID PANEL|Medicare|MEDICARE ACUTE|2.11||||2.11||| 89051|EAP|0300|WBC & DIFFERENTIAL CSF|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.11||||2.11||| 89051|EAP|0300|BODY FLUID PANEL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.11||||||| 89051|EAP|0300|WBC & DIFFERENTIAL CSF|Managed Medicaid|MEDICAID AMERIGROUP|2.11||||||| 89051|EAP|0300|WBC & DIFFERENTIAL CSF|Managed Medicaid|MEDICAID SUPERIOR|2.11||||||| 89051|EAP|0300|WBC & DIFFERENTIAL CSF|Medicaid|MEDICAID|2.11||||2.11||| 89051|EAP|0300|BODY FLUID PANEL|United Medicare Advantage|UHC MEDICARE GOLD MA|2.11||||||| 89051|EAP|0300|BODY FLUID PANEL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.11||||||| 89051|EAP|0300|BODY FLUID PANEL|Blue Cross PPO Specialty|BCBSTX OTHER|2.11||||||| 89051|EAP|0300|BODY FLUID PANEL|Humana Medicare Advantage|HUMANA MA|2.11||||||| 89051|EAP|0300|BODY FLUID PANEL|Blue Cross PPO Specialty|BCBSTX PPO|2.11||||2.11||| 89051|EAP|0300|BODY FLUID PANEL|Aenta Medicare Advantage|AETNA MEDICARE MA|||||2.11||| 89051|EAP|0300|WBC & DIFFERENTIAL CSF|Blue Cross HMO Specialty|BCBSTX HMO|2.11||||||| 89055|EAP|0300|FECAL LEUCOCYTE|Blue Cross HMO Specialty|BCBSTX HMO|163.25||||||| 89055|EAP|0300|FECAL LEUCOCYTE|Aenta Medicare Advantage|AETNA MEDICARE MA|163.25||||163.25||| 89055|EAP|0300|FECAL LEUCOCYTE|Humana Medicare Advantage|HUMANA MA|163.25||||||| 89055|EAP|0300|FECAL LEUCOCYTE|Brinson Benefits|THE HEALTH PLAN SMITH CO|163.25||||||| 89055|EAP|0300|FECAL LEUCOCYTE|Cigna|CIGNA|163.25||||||| 89055|EAP|0300|FECAL LEUCOCYTE|Blue Cross PPO Specialty|BCBSTX OTHER|||||38.25||| 89055|EAP|0300|FECAL LEUCOCYTE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|163.25||||38.25||| 89055|EAP|0300|FECAL LEUCOCYTE|Blue Cross PPO Specialty|BCBSTX PPO|||||100.75||| 89055|EAP|0300|FECAL LEUCOCYTE|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||38.25||| 89055|EAP|0300|FECAL LEUCOCYTE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||163.25||| 89055|EAP|0300|FECAL LEUCOCYTE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||100.75||| 89055|EAP|0300|FECAL LEUCOCYTE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|163.25||||||| 89055|EAP|0300|FECAL LEUCOCYTE|Medicaid|SUPERIOR HEALTHPLAN CHIP|163.25||||38.25||| 89055|EAP|0300|FECAL LEUCOCYTE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|163.25||||163.25||| 89055|EAP|0300|FECAL LEUCOCYTE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|163.25||||||| 89055|EAP|0300|FECAL LEUCOCYTE|Medicaid|MOLINA HEALTHCARE OF TEXAS|163.25||||||| 89055|EAP|0300|FECAL LEUCOCYTE|Medicaid|MEDICAID|163.25||||||| 89055|EAP|0300|FECAL LEUCOCYTE|Managed Medicaid|MEDICAID AMERIGROUP|||||38.25||| 89055|EAP|0300|FECAL LEUCOCYTE|Managed Medicaid|MEDICAID SUPERIOR|163.25||||163.25||| 89055|EAP|0300|FECAL LEUCOCYTE|NON CONTRACTED|COMMERCIAL OTHER 1|163.25||||||| 89055|EAP|0300|FECAL LEUCOCYTE|Medicare|MEDICARE ACUTE|163.25||||38.25||| 89060|EAP|0300|CRYSTAL ID, BODY FLIUD EX|Medicare|MEDICARE ACUTE|||||0.64||| 89060|EAP|0300|CRYSTAL ID, BODY FLIUD EX|United Medicare Advantage|UHC MEDICARE GOLD MA|2.74||||||| 89060|EAP|0300|CRYSTAL ID, BODY FLIUD EX|Blue Cross PPO Specialty|BCBSTX PPO|||||0.64||| 89060|EAP|0300|CRYSTAL ID, BODY FLIUD EX|Aenta Medicare Advantage|AETNA MEDICARE MA|||||0.64||| 89060|EAP|0300|CRYSTAL ID, BODY FLIUD EX|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.64||| 897|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|52,374.38||||||| 897|DRG||ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC|Medicaid|MEDICAID|9,472.76|13456.98|13456.98|13456.98|||| 90|DRG||CONCUSSION W/O CC/MCC|Medicare|MEDICARE ACUTE|30.86|8704.71|8704.71|8704.71|||| 902|DRG||WOUND DEBRIDEMENTS FOR INJURIES W CC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|29,837.30|25820.01|25820.01|25820.01|||| 90371|ERX|0636|HEP B IMMUNE GLOB 110 UNI|Medicaid|MEDICAID|456.40||||||| 90375|ERX|0636|RABIES IMMUNE GLOB 150 UN|Blue Cross PPO Specialty|BCBSTX PPO|||||1,619.07||| 90375|ERX|0636|RABIES IMMUNE GLOB 150 UN|Managed Medicaid|MEDICAID SUPERIOR|||||1,619.07||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|NON CONTRACTED|COMMERCIAL OTHER 1|||||3.28||| 90471|EAP|0771|HEP B IMMUNIZATION ADM|Medicaid|MOLINA HEALTHCARE OF TEXAS|14.85||||||| 90471|EAP|0771|HEP B IMMUNIZATION ADM|Medicaid|MEDICAID|14.85||||||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|Medicaid|MEDICAID PCCM|||||3.28||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|Tricare|TRICARE EAST REGION|||||3.28||| 90471|EAP|0771|HEP B IMMUNIZATION ADM|Tricare|TRICARE EAST REGION|14.85||||||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|Medicare|MEDICARE ACUTE|3.28||||3.28||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||3.28||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|Medicaid|MEDICAID|||||3.28||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||3.28||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|Managed Medicaid|MEDICAID SUPERIOR|||||3.28||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||3.28||| 90471|EAP|0771|HEP B IMMUNIZATION ADM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|14.85||||||| 90471|EAP|0771|HEP B IMMUNIZATION ADM|Managed Medicaid|MEDICAID AMERIGROUP|14.85||||||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||3.28||| 90471|EAP|0940|VACCINE ADM ONE|Managed Medicaid|MEDICAID SUPERIOR|||||405.25||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|Workers Compensation|WORKERS COMPENSATION OTHER|||||3.28||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|Managed Medicaid|MEDICAID AMERIGROUP|||||3.28||| 90471|EAP|0771|HEP B IMMUNIZATION ADM|Managed Medicaid|MEDICAID SUPERIOR|14.85||||||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||3.28||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.28||||3.28||| 90471|EAP|0771|INJ ADM VACCINE ONE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||3.28||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||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 Healthcare|UNITED HEALTHCARE|||||3.28||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||3.28||| 90471|EAP|0771|HEP B IMMUNIZATION ADM|United Healthcare|UNITED HEALTHCARE OTHER|14.85||||||| 90471|EAP|0771|HEP B IMMUNIZATION ADM|United Healthcare|UNITED HEALTHCARE|14.85||||||| 90471|EAP|0771|HEP B IMMUNIZATION ADM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|14.85||||||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||3.28||| 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|14.85||||||| 90471|EAP|0771|HEP B IMMUNIZATION ADM|NON CONTRACTED|COMMERCIAL OTHER 1|14.85||||||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|Blue Cross HMO Specialty|BCBSTX HMO|||||3.28||| 90471|EAP|0771|HEP B IMMUNIZATION ADM|Blue Cross HMO Specialty|BCBSTX HMO|14.85||||||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||3.28||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||3.28||| 90471|EAP|0771|HEP B IMMUNIZATION ADM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|14.85||||||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|Access Direct Platinum|HEALTHFIRST TPA UMR|||||3.28||| 90471|EAP|0771|HEP B IMMUNIZATION ADM|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|14.85||||||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|Blue Cross PPO Specialty|BCBSTX PPO|3.28||||3.28||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|Humana Medicare Advantage|HUMANA MA|||||3.28||| 90471|EAP|0771|HEP B IMMUNIZATION ADM|Blue Cross PPO Specialty|BCBSTX PPO|14.85||||||| 90471|EAP|0450|IMM ADMIN ONE VACCINE|Cigna|CIGNA|||||3.28||| 90471|EAP|0771|HEP B IMMUNIZATION ADM|Cigna|CIGNA|14.85||||||| 906|DRG||HAND PROCEDURES FOR INJURIES|Blue Cross PPO Specialty|BCBSTX PPO|30,177.60|7636.38|7636.38|7636.38|||| 90675|ERX|0636|RABIES VACCINE,PCEC 2.5 U|Managed Medicaid|MEDICAID SUPERIOR|||||1,688.87||| 90675|ERX|0636|RABIES VACCINE,PCEC 2.5 U|Blue Cross PPO Specialty|BCBSTX PPO|||||1,688.87||| 90686|ERX|0250|INFLUENZA VACCINE (FLUVIR|Veterans Affairs|VETERANS ADMINISTRATION|100.35||||||| 90686|ERX|0250|INFLUENZA VACCINE (FLUVIR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|100.35||||||| 90686|ERX|0250|INFLUENZA VACCINE (FLUVIR|Blue Cross HMO Specialty|BCBSTX HMO|||||100.35||| 90686|ERX|0250|INFLUENZA VACCINE (FLUVIR|Aetna|AETNA PPO|100.35||||||| 90686|ERX|0250|INFLUENZA VACCINE (FLUVIR|Medicare|MEDICARE ACUTE|100.35||||||| 90686|ERX|0250|INFLUENZA VACCINE (FLUVIR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|100.35||||||| 90686|ERX|0250|INFLUENZA VACCINE (FLUVIR|Medicaid|MEDICAID|100.35||||||| 90715|ERX|0250|TET-DIPH-PERTUS(ACEL) VAC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||238.05||| 90715|ERX|0250|TET-DIPH-PERTUS(ACEL) VAC|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||238.05||| 90715|ERX|0250|TET-DIPH-PERTUS(ACEL) VAC|Medicaid|MEDICAID PCCM|||||238.05||| 90715|ERX|0250|TET-DIPH-PERTUS(ACEL) VAC|NON CONTRACTED|COMMERCIAL OTHER 1|||||238.05||| 90715|ERX|0250|TET-DIPH-PERTUS(ACEL) VAC|Medicare|MEDICARE ACUTE|238.05||||238.05||| 90715|ERX|0250|TET-DIPH-PERTUS(ACEL) VAC|United Healthcare|UNITED HEALTHCARE|||||238.05||| 90715|ERX|0250|TET-DIPH-PERTUS(ACEL) VAC|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||238.05||| 90715|ERX|0250|TET-DIPH-PERTUS(ACEL) VAC|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||238.05||| 90715|ERX|0250|TET-DIPH-PERTUS(ACEL) VAC|Cigna|CIGNA|||||238.05||| 90715|ERX|0250|TET-DIPH-PERTUS(ACEL) VAC|Tricare|TRICARE EAST REGION|||||238.05||| 90715|ERX|0250|TET-DIPH-PERTUS(ACEL) VAC|Managed Medicaid|MEDICAID SUPERIOR|||||238.05||| 90715|ERX|0250|TET-DIPH-PERTUS(ACEL) VAC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||238.05||| 90715|ERX|0250|TET-DIPH-PERTUS(ACEL) VAC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||238.05||| 90715|ERX|0250|TET-DIPH-PERTUS(ACEL) VAC|Managed Medicaid|MEDICAID AMERIGROUP|||||238.05||| 90715|ERX|0250|TET-DIPH-PERTUS(ACEL) VAC|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||238.05||| 90715|ERX|0250|TET-DIPH-PERTUS(ACEL) VAC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||238.05||| 90715|ERX|0250|TET-DIPH-PERTUS(ACEL) VAC|Access Direct Platinum|HEALTHFIRST TPA UMR|||||238.05||| 90715|ERX|0250|TET-DIPH-PERTUS(ACEL) VAC|Medicaid|MEDICAID|||||238.05||| 90715|ERX|0250|TET-DIPH-PERTUS(ACEL) VAC|Blue Cross PPO Specialty|BCBSTX PPO|238.05||||238.05||| 90715|ERX|0250|TET-DIPH-PERTUS(ACEL) VAC|Blue Cross HMO Specialty|BCBSTX HMO|||||238.05||| 90715|ERX|0250|TET-DIPH-PERTUS(ACEL) VAC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||238.05||| 90715|ERX|0250|TET-DIPH-PERTUS(ACEL) VAC|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||238.05||| 90715|ERX|0250|TET-DIPH-PERTUS(ACEL) VAC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|238.05||||238.05||| 90715|ERX|0250|TET-DIPH-PERTUS(ACEL) VAC|United Medicare Advantage|UHC MEDICARE GOLD MA|||||238.05||| 90715|ERX|0250|TET-DIPH-PERTUS(ACEL) VAC|Workers Compensation|UT EMPLOYEE INJURY|||||238.05||| 90715|ERX|0250|TET-DIPH-PERTUS(ACEL) VAC|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||238.05||| 90715|ERX|0250|TET-DIPH-PERTUS(ACEL) VAC|Workers Compensation|WORKERS COMPENSATION OTHER|||||238.05||| 90715|ERX|0250|TET-DIPH-PERTUS(ACEL) VAC|Humana Medicare Advantage|HUMANA MA|||||238.05||| 90732|ERX|0636|PNEUMOCOCCAL VACC 25MCG/0|Veterans Affairs|VETERANS ADMINISTRATION|397.75||||||| 90732|ERX|0636|PNEUMOCOCCAL VACC 25MCG/0|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|397.75||||||| 90732|ERX|0636|PNEUMOCOCCAL VACC 25MCG/0|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|397.75||||397.75||| 90732|ERX|0636|PNEUMOCOCCAL VACC 25MCG/0|Aetna|AETNA PPO|397.75||||||| 90732|ERX|0636|PNEUMOCOCCAL VACC 25MCG/0|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|397.75||||||| 90732|ERX|0636|PNEUMOCOCCAL VACC 25MCG/0|Aenta Medicare Advantage|AETNA MEDICARE 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|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|United Medicare Advantage|UHC MEDICARE GOLD MA|397.75||||397.75||| 90732|ERX|0636|PNEUMOCOCCAL VACC 25MCG/0|Medicaid|MEDICAID|397.75||||||| 90732|ERX|0636|PNEUMOCOCCAL VACC 25MCG/0|NON CONTRACTED|COMMERCIAL OTHER 1|397.75||||||| 90732|ERX|0636|PNEUMOCOCCAL VACC 25MCG/0|Rusk State Hospital|RUSK STATE HOSP|397.75||||||| 90732|ERX|0636|PNEUMOCOCCAL VACC 25MCG/0|UTMB|UTMB CORRECTIONAL MANAGED CARE|397.75||||||| 90732|ERX|0636|PNEUMOCOCCAL VACC 25MCG/0|Medicare|MEDICARE PART B ONLY IP|397.75||||||| 90732|ERX|0636|PNEUMOCOCCAL VACC 25MCG/0|Medicare|MEDICARE ACUTE|397.75||||397.75||| 90732|ERX|0636|PNEUMOCOCCAL VACC 25MCG/0|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|397.75||||||| 90732|ERX|0636|PNEUMOCOCCAL VACC 25MCG/0|Managed Medicare|HEALTHSPRING MA|397.75||||||| 90732|ERX|0636|PNEUMOCOCCAL VACC 25MCG/0|United Medicare Advantage|AARP UHC WEST COMPLETE MA|397.75||||397.75||| 90732|ERX|0636|PNEUMOCOCCAL VACC 25MCG/0|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|397.75||||||| 90732|ERX|0636|PNEUMOCOCCAL VACC 25MCG/0|Managed Medicaid|MEDICAID UNITED HEALTHCARE|397.75||||||| 90732|ERX|0636|PNEUMOCOCCAL VACC 25MCG/0|Managed Medicaid|MEDICAID SUPERIOR|397.75||||||| 90732|ERX|0636|PNEUMOCOCCAL VACC 25MCG/0|Managed Medicaid|MEDICAID AMERIGROUP|397.75||||||| 90782|EAP|0450||Workers Compensation|WORKERS COMPENSATION OTHER|||||3.28||| 90782|EAP|0450||Workers Compensation|UT EMPLOYEE INJURY|||||3.28||| 908|DRG||OTHER O.R. PROCEDURES FOR INJURIES W CC|Medicare|MEDICARE ACUTE|44,900.73|15467.565|15467.565|7578.62|||| 908|DRG||OTHER O.R. PROCEDURES FOR INJURIES W CC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|26,191.10|7578.62|15467.565|7578.62|||| 908|DRG||OTHER O.R. PROCEDURES FOR INJURIES W CC|Blue Cross PPO Specialty|BCBSTX PPO|58,400.40|8256.17|15467.565|7578.62|||| 909|DRG||OTHER O.R. PROCEDURES FOR INJURIES W/O CC/MCC|Humana Medicare Advantage|HUMANA MA|31,945.55|11961.05|11961.05|11912.88|||| 909|DRG||OTHER O.R. PROCEDURES FOR INJURIES W/O CC/MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|56,213.55|11912.88|11961.05|11912.88|||| 91|DRG||OTHER DISORDERS OF NERVOUS SYSTEM W MCC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|110,411.47|13005.33|13005.33|13005.33|||| 91120|EAP|0750|RECTAL SESATION TONE & CO|Medicare|MEDICARE ACUTE|||||9.60||| 91120|EAP|0750|RECTAL SESATION TONE & CO|Tricare|TRICARE EAST REGION|||||9.60||| 91120|EAP|0750|RECTAL SESATION TONE & CO|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||9.60||| 91120|EAP|0750|RECTAL SESATION TONE & CO|Blue Cross PPO Specialty|BCBSTX PPO|||||9.60||| 91120|EAP|0750|RECTAL SESATION TONE & CO|Humana Medicare Advantage|HUMANA MA|||||9.60||| 91120|EAP|0750|RECTAL SESATION TONE & CO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||9.60||| 91122|EAP|0750|ANORECTAL MANOMETRY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,415.25||| 91122|EAP|0750|ANORECTAL MANOMETRY|Blue Cross PPO Specialty|BCBSTX PPO|||||1,415.25||| 91122|EAP|0750|ANORECTAL MANOMETRY|Humana Medicare Advantage|HUMANA MA|||||1,415.25||| 91122|EAP|0750|ANORECTAL MANOMETRY|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1,415.25||| 91122|EAP|0750|ANORECTAL MANOMETRY|Tricare|TRICARE EAST REGION|||||1,415.25||| 91122|EAP|0750|ANORECTAL MANOMETRY|Medicare|MEDICARE ACUTE|||||1,415.25||| 917|DRG||POISONING & TOXIC EFFECTS OF DRUGS W MCC|Medicare|MEDICARE ACUTE|47,506.75|10201.03|14618.83|10201.03|||| 917|DRG||POISONING & TOXIC EFFECTS OF DRUGS W MCC|United Healthcare|UNITED HEALTHCARE|27,216.15|14618.83|14618.83|10201.03|||| 917|DRG||POISONING & TOXIC EFFECTS OF DRUGS W MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|28,701.75|13933.81|14618.83|10201.03|||| 918|DRG||POISONING & TOXIC EFFECTS OF DRUGS W/O MCC|Blue Cross PPO Specialty|BCBSTX PPO|22,067.83|3138.98|8328.74|3138.98|||| 918|DRG||POISONING & TOXIC EFFECTS OF DRUGS W/O MCC|Medicare|MEDICARE ACUTE|28,000.40|8266.59|8328.74|3138.98|||| 918|DRG||POISONING & TOXIC EFFECTS OF DRUGS W/O MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|204.75|8328.74|8328.74|3138.98|||| 920|DRG||COMPLICATIONS OF TREATMENT W CC|Medicare|MEDICARE ACUTE|40,510.40|9621.81|9621.81|9621.81|||| 921|DRG||COMPLICATIONS OF TREATMENT W/O CC/MCC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|21,386.55|9221.54|9221.54|2488.65|||| 921|DRG||COMPLICATIONS OF TREATMENT W/O CC/MCC|Blue Cross HMO Specialty|BCBSTX HMO|28,665.50|2488.65|9221.54|2488.65|||| 921|DRG||COMPLICATIONS OF TREATMENT W/O CC/MCC|Aenta Medicare Advantage|AETNA MEDICARE MA|47,059.55|7631.79|9221.54|2488.65|||| 923|DRG||OTHER INJURY, POISONING & TOXIC EFFECT DIAG W/O MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|59,684.25|9543.13|9543.13|8855.51|||| 923|DRG||OTHER INJURY, POISONING & TOXIC EFFECT DIAG W/O MCC|Humana Medicare Advantage|HUMANA MA|21,915.75|8855.51|9543.13|8855.51|||| 92611|EAP|0320|MBS EVAL OF SWALLOWING FU|United Medicare Advantage|UHC MEDICARE GOLD MA|||||8.75||| 92611|EAP|0320|MBS EVAL OF SWALLOWING FU|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||8.75||| 92611|EAP|0320|MBS EVAL OF SWALLOWING FU|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||8.75||| 92611|EAP|0320|MBS EVAL OF SWALLOWING FU|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||8.75||| 92611|EAP|0320|MBS EVAL OF SWALLOWING FU|Blue Cross PPO Specialty|BCBSTX PPO|||||8.75||| 92611|EAP|0320|MBS EVAL OF SWALLOWING FU|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||8.75||| 92611|EAP|0320|MBS EVAL OF SWALLOWING FU|Medicare|MEDICARE ACUTE|8.75||||8.75||| 92611|EAP|0320|MBS EVAL OF SWALLOWING FU|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||8.75||| 92611|EAP|0320|MBS EVAL OF SWALLOWING FU|Humana Medicare Advantage|HUMANA MA|8.75||||8.75||| 92950|EAP|0450|CPR|Medicare|MEDICARE ACUTE|12.50||||12.50||| 92950|EAP|0450|CPR|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||12.50||| 92950|EAP|0450|CPR|Medicaid|MEDICAID|12.50||||12.50||| 92950|EAP|0450|CPR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||12.50||| 92950|EAP|0450|CPR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||12.50||| 92950|EAP|0450|CPR|Blue Cross PPO Specialty|BCBSTX PPO|||||12.50||| 92950|EAP|0450|CPR|Humana Medicare Advantage|HUMANA MA|||||12.50||| 92950|EAP|0450|CPR|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||12.50||| 92960|EAP|0450|CARDIOVERSION EXTERNAL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1,291.50||| 92960|EAP|0450|CARDIOVERSION EXTERNAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1,291.50||| 93|DRG||OTHER DISORDERS OF NERVOUS SYSTEM W/O CC/MCC|Medicare|MEDICARE ACUTE|173.44|7514.26|7514.26|7514.26|||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|6.64||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Access Direct Platinum|HEALTHFIRST TPA UMR|||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6.64||||6.64||| 93005|EAP|0730|CLINIC-ELECTROCARDIOGRAM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6.64||||144.25||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Aetna|AETNA OTHER|6.64||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Aenta Medicare Advantage|AETNA MEDICARE MA|6.64||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|6.64||||||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|6.64||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|6.64||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Blue Cross PPO Specialty|BCBSTX PPO|6.64||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Cigna|CIGNA|6.64||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Cigna|CIGNA|||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Blue Cross PPO Specialty|BCBSTX OTHER|6.64||||6.64||| 93005|EAP|0730|CLINIC-ELECTROCARDIOGRAM|Humana Medicare Advantage|HUMANA MA|6.64||||144.25||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|United Healthcare|UNITED HEALTHCARE|6.64||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Veterans Affairs|VETERANS ADMINISTRATION|6.64||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|6.64||||||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|United Healthcare|UMR UNITED MEDICAL RESOURCES|6.64||||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|United Medicare Advantage|AARP UHC WEST COMPLETE MA|6.64||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Workers Compensation|UT EMPLOYEE INJURY|6.64||||||| 93005|EAP|0730|CLINIC-ELECTROCARDIOGRAM|United Medicare Advantage|UHC MEDICARE GOLD MA|6.64||||144.25||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|United Healthcare|UNITED HEALTHCARE OTHER|6.64||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6.64||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|United Healthcare|TML GROUP BENEFITS|6.64||||||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|United Healthcare|GEHA|||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Workers Compensation|WORKERS COMPENSATION OTHER|6.64||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|6.64||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Managed Medicare|HOSPICE OF EAST TEXAS|6.64||||||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Managed Medicare|BCBS MEDICARE PPO MA|||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6.64||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Humana Medicare Advantage|HUMANA MA|6.64||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Managed Medicaid|MEDICAID SUPERIOR|6.64||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|6.64||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Managed Medicare|HEALTHSPRING MA|6.64||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Managed Medicaid|MEDICAID AMERIGROUP|6.64||||6.64||| 93005|EAP|0730|CLINIC-ELECTROCARDIOGRAM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6.64||||144.25||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Blue Cross HMO Specialty|BCBSTX HMO|6.64||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Medicare|MEDICARE PART B ONLY IP|6.64||||||| 93005|EAP|0730|CLINIC-ELECTROCARDIOGRAM|Medicare|MEDICARE ACUTE|6.64||||144.25||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|NON CONTRACTED|COMMERCIAL OTHER 2|6.64||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|NON CONTRACTED|COMMERCIAL OTHER 1|6.64||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Medicaid|SUPERIOR HEALTHPLAN CHIP|6.64||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Medicaid|MEDICAID HMO|||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|PHCS|HUMANA INSURANCE|||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Aetna|AETNA PPO|6.64||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Medicaid|MEDICAID|6.64||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Medicare|MEDICARE ACUTE|6.64||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Rusk State Hospital|RUSK STATE HOSP|6.64||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Medicaid|MEDICAID PCCM|||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Tricare|TRICARE EAST REGION|6.64||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Medicaid|COUNTY INDIGENT HEALTH OTHER|6.64||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|Medicaid|MEDICAID TEXAS CHILDRENS|||||6.64||| 93005|EAP|0730|ELECTROCARDIOGRAM 3 CHANN|UTMB|UTMB CORRECTIONAL MANAGED CARE|6.64||||6.64||| 93005|EAP|0730|CLINIC-ELECTROCARDIOGRAM|Medicaid|MEDICAID|6.64||||144.25||| 93015|EAP|0482||Medicare|MEDICARE ACUTE|||||2,012.25||| 93015|EAP|0482||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||2,012.25||| 93015|EAP|0482||Managed Medicaid|MEDICAID SUPERIOR|||||2,012.25||| 93015|EAP|0482||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||2,012.25||| 93015|EAP|0482||United Medicare Advantage|UHC MEDICARE GOLD MA|||||2,012.25||| 93017|EAP|0482|STRESS TEST TRACING|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2,012.25||| 93017|EAP|0482|STRESS TEST TRACING|Blue Cross PPO Specialty|BCBSTX PPO|||||2,012.25||| 93017|EAP|0482|STRESS TEST TRACING|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2,012.25||| 93017|EAP|0482|STRESS TEST TRACING|Aenta Medicare Advantage|AETNA MEDICARE MA|2,012.25||||2,012.25||| 93017|EAP|0482|STRESS TEST TRACING|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||2,012.25||| 93017|EAP|0482|STRESS TEST TRACING|Blue Cross HMO Specialty|BCBSTX HMO|||||2,012.25||| 93017|EAP|0482|STRESS TEST TRACING|United Medicare Advantage|UHC MEDICARE GOLD MA|||||2,012.25||| 93017|EAP|0482|STRESS TEST TRACING|Blue Cross PPO Specialty|BCBSTX OTHER|||||2,012.25||| 93017|EAP|0482|STRESS TEST TRACING|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||2,012.25||| 93017|EAP|0482|STRESS TEST TRACING|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2,012.25||| 93017|EAP|0482|STRESS TEST TRACING|United Healthcare|UNITED HEALTHCARE|||||2,012.25||| 93017|EAP|0482|STRESS TEST TRACING|Humana Medicare Advantage|HUMANA MA|2,012.25||||2,012.25||| 93017|EAP|0482|STRESS TEST TRACING|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||2,012.25||| 93017|EAP|0482|STRESS TEST TRACING|Managed Medicare|HEALTHSPRING MA|||||2,012.25||| 93017|EAP|0482|STRESS TEST TRACING|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||2,012.25||| 93017|EAP|0482|STRESS TEST TRACING|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2,012.25||| 93017|EAP|0482|STRESS TEST TRACING|UTMB|UTMB CORRECTIONAL MANAGED CARE|2,012.25||||||| 93017|EAP|0482|STRESS TEST TRACING|NON CONTRACTED|COMMERCIAL OTHER 2|||||2,012.25||| 93017|EAP|0482|STRESS TEST TRACING|NON CONTRACTED|COMMERCIAL OTHER 1|||||2,012.25||| 93017|EAP|0482|STRESS TEST TRACING|Tricare|TRICARE EAST REGION|||||2,012.25||| 93017|EAP|0482|STRESS TEST TRACING|Medicare|MEDICARE ACUTE|2,012.25||||2,012.25||| 93225|EAP|0730|CARDIO NET HOLTER HOOK-UP|Medicare|MEDICARE ACUTE|||||31.25||| 93225|EAP|0730|CARDIO NET HOLTER HOOK-UP|NON CONTRACTED|COMMERCIAL OTHER 1|||||31.25||| 93225|EAP|0730|CARDIO NET HOLTER HOOK-UP|United Healthcare|UNITED HEALTHCARE|||||31.25||| 93225|EAP|0730|CARDIO NET HOLTER HOOK-UP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||31.25||| 93225|EAP|0730|CARDIO NET HOLTER HOOK-UP|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||31.25||| 93225|EAP|0730|CARDIO NET HOLTER HOOK-UP|Blue Cross HMO Specialty|BCBSTX HMO|||||31.25||| 93225|EAP|0730|CARDIO NET HOLTER HOOK-UP|Humana Medicare Advantage|HUMANA MA|31.25||||||| 93303|EAP|0483|ECHO TTE 2D CONGENTIAL CO|Blue Cross PPO Specialty|BCBSTX PPO|||||1,628.75||| 93303|EAP|0483|ECHO TTE 2D CONGENTIAL CO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,628.75||| 93303|EAP|0483|ECHO TTE 2D CONGENTIAL CO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,628.75||| 93303|EAP|0483|ECHO TTE 2D CONGENTIAL CO|Managed Medicaid|MEDICAID SUPERIOR|||||1,628.75||| 93303|EAP|0483|ECHO TTE 2D CONGENTIAL CO|Managed Medicaid|MEDICAID AMERIGROUP|||||1,628.75||| 93303|EAP|0483|ECHO TTE 2D CONGENTIAL CO|Medicaid|MEDICAID|||||1,628.75||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Medicaid|SUPERIOR HEALTHPLAN CHIP|50.53||||||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Medicaid|MEDICAID|50.53||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|NON CONTRACTED|COMMERCIAL OTHER 1|50.53||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Tricare|TRICARE FOR LIFE|||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Medicare|MEDICARE PART B ONLY IP|50.53||||||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Managed Medicare|HEALTHSPRING MA|50.53||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|50.53||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|50.53||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Medicare|MEDICARE ACUTE|50.53||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Managed Medicaid|MEDICAID AMERIGROUP|50.53||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Veterans Affairs|VETERANS ADMINISTRATION|||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Managed Medicaid|MEDICAID SUPERIOR|50.53||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|UTMB|UTMB CORRECTIONAL MANAGED CARE|50.53||||||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|50.53||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Workers Compensation|WORKERS COMPENSATION OTHER|||||50.53||| 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|United Medicare Advantage|AARP UHC WEST COMPLETE MA|50.53||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|United Healthcare|UNITED HEALTHCARE OTHER|||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|United Healthcare|UNITED HEALTHCARE|||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|50.53||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Aenta Medicare Advantage|AETNA MEDICARE MA|50.53||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Blue Cross HMO Specialty|BCBSTX HMO|||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Aetna|AETNA PPO|||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Blue Cross PPO Specialty|BCBSTX PPO|50.53||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Blue Cross PPO Specialty|BCBSTX OTHER|50.53||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Humana Medicare Advantage|HUMANA MA|50.53||||50.53||| 93306|EAP|0483|ECHOCARDIOGRAM 2D M DOPLR|Cigna|CIGNA|50.53||||50.53||| 93351|EAP|0483|ECHO STRESS|Blue Cross PPO Specialty|BCBSTX PPO|||||16.60||| 93351|EAP|0483|ECHO STRESS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||16.60||| 93351|EAP|0483|ECHO STRESS|Medicare|MEDICARE ACUTE|||||16.60||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1,874.75||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,874.75||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|Managed Medicaid|MEDICAID SUPERIOR|||||1,874.75||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1,874.75||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|Medicaid|MEDICAID|||||1,874.75||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|Tricare|TRICARE EAST REGION|||||1,874.75||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|Medicare|MEDICARE ACUTE|1,874.75||||1,874.75||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,874.75||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,874.75||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|1,874.75||||1,874.75||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|United Healthcare|UNITED HEALTHCARE|||||1,874.75||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,874.75||||1,874.75||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|Blue Cross HMO Specialty|BCBSTX HMO|||||1,874.75||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,874.75||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|Blue Cross PPO Specialty|BCBSTX PPO|||||1,874.75||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|Aenta Medicare Advantage|AETNA MEDICARE MA|1,874.75||||1,874.75||| 93880|EAP|0921|CAROTID DUPLEX BILATERAL|Humana Medicare Advantage|HUMANA MA|1,874.75||||1,874.75||| 93922|EAP|0402|ABI LOWER EXTREMITY|Humana Medicare Advantage|HUMANA MA|619.75||||||| 93922|EAP|0921|ANKLE BRACHIAL INDEX/MOD|Humana Medicare Advantage|HUMANA MA|||||372.25||| 93922|EAP|0402|ABI LOWER EXTREMITY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|619.75||||||| 93922|EAP|0402|ABI LOWER EXTREMITY|Aenta Medicare Advantage|AETNA MEDICARE MA|||||619.75||| 93922|EAP|0402|ABI LOWER EXTREMITY|United Medicare Advantage|UHC MEDICARE GOLD MA|||||619.75||| 93922|EAP|0402|ABI LOWER EXTREMITY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||619.75||| 93922|EAP|0402|ABI LOWER EXTREMITY|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||619.75||| 93922|EAP|0921|ANKLE BRACHIAL INDEX/MOD|Medicare|MEDICARE ACUTE|||||372.25||| 93922|EAP|0402|ABI LOWER EXTREMITY|Medicare|MEDICARE ACUTE|||||619.75||| 93922|EAP|0402|ABI LOWER EXTREMITY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||619.75||| 93925|EAP|0921|DUPLEX BIL LOWER EXT ART|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,797.50||| 93925|EAP|0921|DUPLEX BIL LOWER EXT ART|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,797.50||||||| 93925|EAP|0921|DUPLEX BIL LOWER EXT ART|Managed Medicaid|MEDICAID AMERIGROUP|||||1,797.50||| 93925|EAP|0921|DUPLEX BIL LOWER EXT ART|Medicare|MEDICARE ACUTE|||||1,797.50||| 93925|EAP|0921|DUPLEX BIL LOWER EXT ART|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1,797.50||| 93925|EAP|0921|DUPLEX BIL LOWER EXT ART|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,797.50||| 93925|EAP|0921|DUPLEX BIL LOWER EXT ART|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1,797.50||| 93925|EAP|0921|DUPLEX BIL LOWER EXT ART|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,797.50||||1,797.50||| 93925|EAP|0921|DUPLEX BIL LOWER EXT ART|Humana Medicare Advantage|HUMANA MA|1,797.50||||1,797.50||| 93925|EAP|0921|DUPLEX BIL LOWER EXT ART|Blue Cross PPO Specialty|BCBSTX PPO|||||1,797.50||| 93926|EAP|0921|DUPLEX EXT.RT.LOWER ARTER|Humana Medicare Advantage|HUMANA MA|1,139.25||||1,139.25||| 93926|EAP|0921|DUPLEX EXT.LT.LOWER ARTER|Humana Medicare Advantage|HUMANA MA|1,139.25||||1,139.25||| 93926|EAP|0921|DUPLEX EXT.LT.LOWER ARTER|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,139.25||| 93926|EAP|0921|DUPLEX EXT.RT.LOWER ARTER|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1,139.25||| 93926|EAP|0921|DUPLEX EXT.LT.LOWER ARTER|United Medicare Advantage|AARP UHC WEST COMPLETE 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|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,139.25||| 93926|EAP|0921|DUPLEX EXT.RT.LOWER ARTER|Veterans Affairs|VETERANS ADMINISTRATION|||||1,139.25||| 93926|EAP|0921|DUPLEX EXT.RT.LOWER ARTER|Medicare|MEDICARE ACUTE|||||1,139.25||| 93926|EAP|0921|DUPLEX EXT.LT.LOWER ARTER|Medicare|MEDICARE ACUTE|||||1,139.25||| 93926|EAP|0921|DUPLEX EXT.RT.LOWER ARTER|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,139.25||| 93926|EAP|0921|DUPLEX EXT.RT.LOWER ARTER|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1,139.25||| 93926|EAP|0921|DUPLEX EXT.LT.LOWER ARTER|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,139.25||| 93926|EAP|0921|DUPLEX EXT.LT.LOWER ARTER|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1,139.25||| 93930|EAP|0921|DUPLEX BIL UPPER EXT ART|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1,797.50||| 93931|EAP|0921|DUPLEX EXT. RT. UPPER ART|Managed Medicare|HEALTHSPRING MA|||||1,139.25||| 93931|EAP|0921|DUPLEX EXT.LT.UPPER ARTER|Medicare|MEDICARE ACUTE|||||1,139.25||| 93931|EAP|0921|DUPLEX EXT.LT.UPPER ARTER|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,139.25||| 93931|EAP|0921|DUPLEX EXT. RT. UPPER ART|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1,139.25||| 93931|EAP|0921|DUPLEX EXT.LT.UPPER ARTER|Humana Medicare Advantage|HUMANA MA|||||1,139.25||| 93931|EAP|0921|DUPLEX EXT.LT.UPPER ARTER|Aetna|AETNA OTHER|1,139.25||||||| 93931|EAP|0921|DUPLEX EXT. RT. UPPER ART|Medicaid|MEDICAID HMO|||||1,139.25||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,800.25||||1,800.25||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1,800.25||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|United Healthcare|UNITED HEALTHCARE OTHER|||||1,800.25||| 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|Blue Cross PPO Specialty|BCBSTX PPO|1,800.25||||1,800.25||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|Humana Medicare Advantage|HUMANA MA|1,800.25||||1,800.25||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|Cigna|CIGNA|1,800.25||||||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|Aenta Medicare Advantage|AETNA MEDICARE MA|1,800.25||||1,800.25||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,800.25||||1,800.25||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|United Medicare Advantage|UHC MEDICARE GOLD MA|1,800.25||||1,800.25||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|Blue Cross HMO Specialty|BCBSTX HMO|1,800.25||||1,800.25||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|NON CONTRACTED|COMMERCIAL OTHER 1|1,800.25||||||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1,800.25||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|Medicaid|MEDICAID|1,800.25||||1,800.25||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1,800.25||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,800.25||||1,800.25||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|Managed Medicaid|MEDICAID SUPERIOR|||||1,800.25||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|Medicare|MEDICARE ACUTE|1,800.25||||1,800.25||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,800.25||||||| 93970|EAP|0921|DUPLEX LOWER EXT VEINS BI|Managed Medicaid|MEDICAID AMERIGROUP|1,800.25||||1,800.25||| 93971|EAP|0921|DUPLEX LOWER EXT RT VEINS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT RT VEINS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT RT VEINS|Managed Medicaid|MEDICAID SUPERIOR|1,191.75||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|Managed Medicaid|MEDICAID SUPERIOR|1,191.75||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,191.75||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT RT VEINS|NON CONTRACTED|COMMERCIAL OTHER 1|||||1,191.75||| 93971|EAP|0921|DUPLEX UPPER EXT RT VEINS|Managed Medicaid|MEDICAID SUPERIOR|1,191.75||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|Medicaid|MEDICAID|1,191.75||||||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|Rusk State Hospital|RUSK STATE HOSP|||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|Medicare|MEDICARE ACUTE|1,191.75||||1,191.75||| 93971|EAP|0921|DUPLEX UPPER EXT RT VEINS|Medicare|MEDICARE ACUTE|1,191.75||||1,191.75||| 93971|EAP|0921|DUPLEX UPPER EXT LT VEINS|Medicare|MEDICARE ACUTE|1,191.75||||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|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,191.75||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,191.75||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT RT VEINS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|Blue Cross HMO Specialty|BCBSTX HMO|1,191.75||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT RT VEINS|Medicare|MEDICARE ACUTE|1,191.75||||1,191.75||| 93971|EAP|0921|DUPLEX UPPER EXT RT VEINS|Aenta Medicare Advantage|AETNA MEDICARE MA|1,191.75||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|Aenta Medicare Advantage|AETNA MEDICARE MA|1,191.75||||1,191.75||| 93971|EAP|0921|DUPLEX UPPER EXT RT 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 UPPER EXT LT VEINS|Blue Cross PPO Specialty|BCBSTX PPO|1,191.75||||1,191.75||| 93971|EAP|0921|DUPLEX UPPER EXT RT VEINS|Humana Medicare Advantage|HUMANA MA|1,191.75||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT RT VEINS|Humana Medicare Advantage|HUMANA MA|1,191.75||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT RT VEINS|Blue Cross PPO Specialty|BCBSTX OTHER|||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|Blue Cross PPO Specialty|BCBSTX OTHER|||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT RT VEINS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,191.75||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|NON CONTRACTED|COMMERCIAL OTHER 1|||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|Managed Medicaid|MEDICAID AMERIGROUP|||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|Humana Medicare Advantage|HUMANA MA|1,191.75||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|Blue Cross PPO Specialty|BCBSTX PPO|1,191.75||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT RT VEINS|Cigna|CIGNA|||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT RT VEINS|Blue Cross PPO Specialty|BCBSTX PPO|1,191.75||||1,191.75||| 93971|EAP|0921|DUPLEX UPPER EXT LT VEINS|Humana Medicare Advantage|HUMANA MA|1,191.75||||1,191.75||| 93971|EAP|0921|DUPLEX UPPER EXT RT VEINS|Managed Medicare|HEALTHSPRING MA|||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|Workers Compensation|WORKERS COMPENSATION OTHER|||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||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 RT VEINS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP 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 LT VEINS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT RT VEINS|Veterans Affairs|VETERANS ADMINISTRATION|||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT RT VEINS|United Healthcare|UNITED HEALTHCARE OTHER|||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|United Healthcare|UNITED HEALTHCARE|||||1,191.75||| 93971|EAP|0921|DUPLEX LOWER EXT LT VEINS|United Healthcare|UNITED HEALTHCARE OTHER|||||1,191.75||| 93975|EAP|0402|DUP SCAN ART/VENOUS ORGAN|United Medicare Advantage|UHC MEDICARE GOLD MA|||||6.19||| 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 Healthcare|UNITED HEALTHCARE OTHER|||||6.19||| 93975|EAP|0402|DUP SCAN ART/VENOUS ORGAN|Blue Cross PPO Specialty|BCBSTX PPO|6.19||||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 PPO Specialty|BCBSTX OTHER|||||6.19||| 93975|EAP|0402|DUP SCAN ART/VENOUS ORGAN|NON CONTRACTED|COMMERCIAL OTHER 1|||||6.19||| 93975|EAP|0402|DUP SCAN ART/VENOUS ORGAN|Blue Cross HMO Specialty|BCBSTX HMO|||||6.19||| 93975|EAP|0402|DUP SCAN ART/VENOUS ORGAN|Medicaid|MEDICAID TEXAS CHILDRENS|||||6.19||| 93975|EAP|0402|DUP SCAN ART/VENOUS ORGAN|Medicaid|MEDICAID HMO|||||6.19||| 93975|EAP|0402|DUP SCAN ART/VENOUS ORGAN|Medicaid|MEDICAID|6.19||||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|Medicare|MEDICARE ACUTE|6.19||||6.19||| 93975|EAP|0402|DUP SCAN ART/VENOUS ORGAN|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||6.19||| 93975|EAP|0402|DUP SCAN ART/VENOUS ORGAN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||6.19||| 93975|EAP|0402|DUP SCAN ART/VENOUS ORGAN|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||6.19||| 93975|EAP|0402|DUP SCAN ART/VENOUS ORGAN|Managed Medicaid|MEDICAID SUPERIOR|||||6.19||| 93975|EAP|0402|DUP SCAN ART/VENOUS ORGAN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||6.19||| 93975|EAP|0402|DUP SCAN ART/VENOUS ORGAN|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||6.19||| 93975|EAP|0402|DUP SCAN ART/VENOUS ORGAN|Managed Medicaid|MEDICAID AMERIGROUP|||||6.19||| 93976|EAP|0921|ABDOMINAL LIMITED VASCULA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,360.75||| 93976|EAP|0921|ABDOMINAL LIMITED VASCULA|Managed Medicaid|MEDICAID SUPERIOR|1,360.75||||||| 93976|EAP|0921|ABDOMINAL LIMITED VASCULA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1,360.75||| 93976|EAP|0921|ABDOMINAL LIMITED VASCULA|NON CONTRACTED|COMMERCIAL OTHER 1|||||1,360.75||| 93976|EAP|0921|ABDOMINAL LIMITED VASCULA|UTMB|UTMB CORRECTIONAL MANAGED CARE|1,360.75||||||| 93976|EAP|0921|ABDOMINAL LIMITED VASCULA|Medicare|MEDICARE ACUTE|1,360.75||||1,360.75||| 93976|EAP|0921|ABDOMINAL LIMITED VASCULA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,360.75||| 93976|EAP|0921|ABDOMINAL LIMITED VASCULA|Cigna|CIGNA|||||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 MEDICARE GOLD MA|||||1,360.75||| 93976|EAP|0921|ABDOMINAL LIMITED VASCULA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,360.75||||1,360.75||| 93976|EAP|0921|ABDOMINAL LIMITED VASCULA|Blue Cross PPO Specialty|BCBSTX PPO|||||1,360.75||| 93976|EAP|0921|ABDOMINAL LIMITED VASCULA|Blue Cross HMO Specialty|BCBSTX HMO|||||1,360.75||| 93976|EAP|0921|ABDOMINAL LIMITED VASCULA|United Medicare Advantage|AARP UHC WEST COMPLETE MA|1,360.75||||1,360.75||| 93978|EAP|0921|AORTA ULTRASOUND COMPLETE|United Medicare Advantage|UHC MEDICARE GOLD MA|1,043.50||||1,043.50||| 93978|EAP|0921|AORTA ULTRASOUND COMPLETE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1,043.50||| 93978|EAP|0921|AORTA ULTRASOUND COMPLETE|Blue Cross PPO Specialty|BCBSTX OTHER|||||1,043.50||| 93978|EAP|0921|AORTA ULTRASOUND COMPLETE|Humana Medicare Advantage|HUMANA MA|1,043.50||||1,043.50||| 93978|EAP|0921|AORTA ULTRASOUND COMPLETE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1,043.50||| 93978|EAP|0921|AORTA ULTRASOUND COMPLETE|Medicare|MEDICARE ACUTE|||||1,043.50||| 940|DRG||O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W CC|Aenta Medicare Advantage|AETNA MEDICARE MA|131,196.25|18040.99|18040.99|18040.99|||| 94002|EAP|0410|NON-INVASIVE VENTILATOR|Managed Medicare|HEALTHSPRING MA|5.01||||||| 94002|EAP|0410|TRACHEAL CARE SYSTEM|Managed Medicaid|MEDICAID SUPERIOR|13.69||||||| 94002|EAP|0410|TRACHEAL CARE SYSTEM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|13.69||||13.69||| 94002|EAP|0410|NON-INVASIVE VENTILATOR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.01||||5.01||| 94002|EAP|0410|NON-INVASIVE VENTILATOR|NON CONTRACTED|COMMERCIAL OTHER 1|5.01||||||| 94002|EAP|0410|TRACHEAL CARE SYSTEM|UTMB|UTMB CORRECTIONAL MANAGED CARE|5.01||||13.69||| 94002|EAP|0410|TRACHEAL CARE SYSTEM|UTMB|UTMB CORRECTIONAL MANAGED CARE|13.69||||13.69||| 94002|EAP|0410|TRACHEAL CARE SYSTEM|Rusk State Hospital|RUSK STATE HOSP|13.69||||13.69||| 94002|EAP|0410|TRACHEAL CARE SYSTEM|Medicaid|MEDICAID|13.69||||||| 94002|EAP|0410|NON-INVASIVE VENTILATOR|Medicaid|MEDICAID|5.01||||||| 94002|EAP|0410|TRACHEAL CARE SYSTEM|Medicare|MEDICARE ACUTE|13.69||||13.69||| 94002|EAP|0410|NON-INVASIVE VENTILATOR|Medicare|MEDICARE PART B ONLY IP|5.01||||||| 94002|EAP|0410|NON-INVASIVE VENTILATOR|Medicare|MEDICARE ACUTE|5.01||||5.01||| 94002|EAP|0410|NON-INVASIVE VENTILATOR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.01||||||| 94002|EAP|0410|NON-INVASIVE VENTILATOR|Veterans Affairs|VETERANS ADMINISTRATION|5.01||||||| 94002|EAP|0410|NON-INVASIVE VENTILATOR|United Medicare Advantage|UHC MEDICARE GOLD MA|5.01||||5.01||| 94002|EAP|0410|TRACHEAL CARE SYSTEM|Rusk State Hospital|RUSK STATE HOSP|5.01||||13.69||| 94002|EAP|0410|TRACHEAL CARE SYSTEM|United Medicare Advantage|AARP UHC WEST COMPLETE MA|5.01||||13.69||| 94002|EAP|0410|NON-INVASIVE VENTILATOR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.01||||||| 94002|EAP|0410|NON-INVASIVE VENTILATOR|Blue Cross PPO Specialty|BCBSTX OTHER|5.01||||||| 94002|EAP|0410|TRACHEAL CARE SYSTEM|Humana Medicare Advantage|HUMANA MA|13.69||||13.69||| 94002|EAP|0410|NON-INVASIVE VENTILATOR|Humana Medicare Advantage|HUMANA MA|5.01||||5.01||| 94002|EAP|0410|TRACHEAL CARE SYSTEM|Aenta Medicare Advantage|AETNA MEDICARE MA|13.69||||||| 94002|EAP|0410|NON-INVASIVE VENTILATOR|Aenta Medicare Advantage|AETNA MEDICARE MA|5.01||||||| 94002|EAP|0410|TRACHEAL CARE SYSTEM|Blue Cross HMO Specialty|BCBSTX HMO|13.69||||13.69||| 94002|EAP|0410|TRACHEAL CARE SYSTEM|United Medicare Advantage|AARP UHC WEST COMPLETE MA|13.69||||13.69||| 94003|EAP|0410|VENTILATOR W-02 MIN 1ST 4|Blue Cross HMO Specialty|BCBSTX HMO|13.69||||13.69||| 94003|EAP|0410|VENTILATOR W-02 MIN 1ST 4|Humana Medicare Advantage|HUMANA MA|13.69||||13.69||| 94003|EAP|0410|VENTILATOR W-02 MIN 1ST 4|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||13.69||| 94003|EAP|0410|VENTILATOR W-02 MIN 1ST 4|Rusk State Hospital|RUSK STATE HOSP|13.69||||13.69||| 94003|EAP|0410|VENTILATOR W-02 MIN 1ST 4|UTMB|UTMB CORRECTIONAL MANAGED CARE|13.69||||969.75||| 94003|EAP|0410|VENTILATOR W-02 MIN 1ST 4|Medicare|MEDICARE ACUTE|13.69||||13.69||| 94003|EAP|0410|VENTILATOR W-02 MIN 1ST 4|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|13.69||||13.69||| 94004|EAP|0410|VENTILATOR W-02 MAX 24 HR|Managed Medicaid|MEDICAID SUPERIOR|24.56||||||| 94004|EAP|0410|VENTILATOR W-02 MAX 24 HR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|24.56||||24.56||| 94004|EAP|0410|VENTILATOR W-02 MAX 24 HR|Rusk State Hospital|RUSK STATE HOSP|24.56||||||| 94004|EAP|0410|VENTILATOR W-02 MAX 24 HR|Medicaid|MEDICAID|24.56||||||| 94004|EAP|0410|VENTILATOR W-02 MAX 24 HR|Medicare|MEDICARE ACUTE|24.56||||||| 94004|EAP|0410|VENTILATOR W-02 MAX 24 HR|UTMB|UTMB CORRECTIONAL MANAGED CARE|24.56||||24.56||| 94004|EAP|0410|VENTILATOR W-02 MAX 24 HR|United Medicare Advantage|AARP UHC WEST COMPLETE MA|24.56||||||| 94004|EAP|0410|VENTILATOR W-02 MAX 24 HR|Humana Medicare Advantage|HUMANA MA|24.56||||24.56||| 94004|EAP|0410|VENTILATOR W-02 MAX 24 HR|Aenta Medicare Advantage|AETNA MEDICARE MA|24.56||||||| 94004|EAP|0410|VENTILATOR W-02 MAX 24 HR|Blue Cross HMO Specialty|BCBSTX HMO|24.56||||||| 94004|EAP|0410|VENTILATOR W-02 MAX 24 HR|United Healthcare|UNITED HEALTHCARE|24.56||||||| 94010|EAP|0460|PULMONARY FUNCTION BEFORE|Aenta Medicare Advantage|AETNA MEDICARE MA|969.25||||||| 94010|EAP|0460|PULMONARY FUNCTION BEFORE|Blue Cross HMO Specialty|BCBSTX HMO|||||969.25||| 94010|EAP|0460|PULMONARY FUNCTION BEFORE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||969.25||| 94010|EAP|0410|CLINIC-SPIROMETRY|Medicare|MEDICARE ACUTE|241.25||||||| 94010|EAP|0460|PULMONARY FUNCTION BEFORE|Medicare|MEDICARE ACUTE|||||969.25||| 94010|EAP|0410|CLINIC-SPIROMETRY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|241.25||||||| 94010|EAP|0460|PULMONARY FUNCTION BEFORE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||969.25||| 94010|EAP|0410|CLINIC-SPIROMETRY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||241.25||| 94060|EAP|0410|PULMONARY FUNCTION PRE PO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||14.49||| 94060|EAP|0410|PULMONARY FUNCTION PRE PO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||14.49||| 94060|EAP|0410|PULMONARY FUNCTION PRE PO|Managed Medicaid|MEDICAID AMERIGROUP|||||14.49||| 94060|EAP|0410|PULMONARY FUNCTION PRE PO|Medicare|MEDICARE ACUTE|||||14.49||| 94060|EAP|0410|PULMONARY FUNCTION PRE PO|UTMB|UTMB CORRECTIONAL MANAGED CARE|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 Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||14.49||| 94060|EAP|0410|PULMONARY FUNCTION PRE PO|Aenta Medicare Advantage|AETNA MEDICARE MA|14.49||||||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||201.25||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Blue Cross PPO Specialty|BCBSTX PPO|201.25||||201.25||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Humana Medicare Advantage|HUMANA MA|201.25||||201.25||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Cigna|CIGNA|201.25||||201.25||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|201.25||||201.25||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|201.25||||201.25||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Aetna|AETNA PPO|||||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 HMO Specialty|BCBSTX HMO|201.25||||201.25||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|201.25||||201.25||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Workers Compensation|UT EMPLOYEE INJURY|201.25||||||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|United Healthcare|UNITED HEALTHCARE 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|Veterans Affairs|VETERANS ADMINISTRATION|201.25||||201.25||| 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|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||201.25||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|United Medicare Advantage|AARP UHC WEST COMPLETE MA|201.25||||201.25||| 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||||201.25||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|United Healthcare|UMR UNITED MEDICAL RESOURCES|201.25||||201.25||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|NON CONTRACTED|COMMERCIAL OTHER 1|201.25||||201.25||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Tricare|TRICARE EAST REGION|||||201.25||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||201.25||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||201.25||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Medicaid|MEDICAID|201.25||||201.25||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Aetna|AETNA OTHER|201.25||||||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||201.25||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Medicare|MEDICARE ACUTE|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|UTMB|UTMB CORRECTIONAL MANAGED CARE|201.25||||201.25||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Medicaid|MEDICAID TEXAS CHILDRENS|||||201.25||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Managed Medicare|WELLCARE CHOICE MA|||||201.25||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Managed Medicare|HEALTHSPRING MA|201.25||||201.25||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Managed Medicare|HOSPICE OF EAST TEXAS|201.25||||||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Rusk State Hospital|RUSK STATE HOSP|201.25||||201.25||| 94640|EAP|0410|UPDRAFT NEBULIZER-EA TRMT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|201.25||||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|COUNTY INDIGENT HEALTH OTHER|||||201.25||| 94660|EAP|0410|CONTIN POS AIRWAY PRESSUR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||5.01||| 94660|EAP|0410|CONTIN POS AIRWAY PRESSUR|Medicaid|MEDICAID|5.01||||||| 94660|EAP|0410|CONTIN POS AIRWAY PRESSUR|United Medicare Advantage|AARP UHC WEST COMPLETE MA|5.01||||||| 94660|EAP|0410|CONTIN POS AIRWAY PRESSUR|United Medicare Advantage|UHC MEDICARE GOLD MA|5.01||||5.01||| 94660|EAP|0410|CONTIN POS AIRWAY PRESSUR|Humana Medicare Advantage|HUMANA MA|5.01||||||| 94664|EAP|0410|SPUTUM INDUCTION|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.98||||1.98||| 94664|EAP|0410|SPUTUM INDUCTION|Aenta Medicare Advantage|AETNA MEDICARE MA|1.98||||||| 94664|EAP|0730|EDUCATION/INITAL|Aenta Medicare Advantage|AETNA MEDICARE MA|4.19||||||| 94664|EAP|0730|EDUCATION/INITAL|Blue Cross HMO Specialty|BCBSTX HMO|4.19||||||| 94664|EAP|0410|SPUTUM INDUCTION|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1.98||| 94664|EAP|0410|SPUTUM INDUCTION|Cigna|CIGNA|||||1.98||| 94664|EAP|0730|EDUCATION/INITAL|Humana Medicare Advantage|HUMANA MA|4.19||||||| 94664|EAP|0730|EDUCATION/INITAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|4.19||||||| 94664|EAP|0410|SPUTUM INDUCTION|Blue Cross PPO Specialty|BCBSTX PPO|1.98||||1.98||| 94664|EAP|0410|SPUTUM INDUCTION|Humana Medicare Advantage|HUMANA MA|252.25||||1.98||| 94664|EAP|0730|EDUCATION/INITAL|Blue Cross PPO Specialty|BCBSTX PPO|4.19||||||| 94664|EAP|0410|SPUTUM INDUCTION|Workers Compensation|UT EMPLOYEE INJURY|1.98||||||| 94664|EAP|0410|SPUTUM INDUCTION|United Medicare Advantage|AARP UHC WEST COMPLETE MA|1.98||||1.98||| 94664|EAP|0410|SPUTUM INDUCTION|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.98||||||| 94664|EAP|0410|SPUTUM INDUCTION|Veterans Affairs|VETERANS ADMINISTRATION|||||1.98||| 94664|EAP|0410|SPUTUM INDUCTION|United Medicare Advantage|UHC MEDICARE GOLD MA|1.98||||||| 94664|EAP|0410|SPUTUM INDUCTION|Humana Medicare Advantage|HUMANA MA|1.98||||1.98||| 94664|EAP|0410|COLD AERO W-02 EA TRMT|Humana Medicare Advantage|HUMANA MA|1,568.75||||252.25||| 94664|EAP|0410|SPUTUM INDUCTION|United Healthcare|UNITED HEALTHCARE|1.98||||1.98||| 94664|EAP|0730|EDUCATION/INITAL|Medicaid|MEDICAID|4.19||||||| 94664|EAP|0410|SPUTUM INDUCTION|Rusk State Hospital|RUSK STATE HOSP|1.98||||1.98||| 94664|EAP|0410|SPUTUM INDUCTION|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||1.98||| 94664|EAP|0410|SPUTUM INDUCTION|Medicaid|MEDICAID|1.98||||1.98||| 94664|EAP|0410|SPUTUM INDUCTION|Medicaid|MEDICAID|252.25||||1.98||| 94664|EAP|0730|EDUCATION/INITAL|Medicare|MEDICARE ACUTE|4.19||||4.19||| 94664|EAP|0410|SPUTUM INDUCTION|Aetna|AETNA OTHER|1,568.75||||1.98||| 94664|EAP|0410|SPUTUM INDUCTION|Medicare|MEDICARE ACUTE|1,568.75||||1.98||| 94664|EAP|0410|SPUTUM INDUCTION|Medicare|MEDICARE ACUTE|1.98||||1.98||| 94664|EAP|0410|SPUTUM INDUCTION|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.98||| 94664|EAP|0410|COLD AERO W-02 EA TRMT|Medicare|MEDICARE ACUTE|252.25||||1.98||| 94664|EAP|0410|SPUTUM INDUCTION|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.98||||||| 94664|EAP|0410|SPUTUM INDUCTION|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,568.75||||1.98||| 94664|EAP|0410|SPUTUM INDUCTION|Managed Medicare|HEALTHSPRING MA|1.98||||||| 94664|EAP|0410|COLD AERO W-02 CONT MAX 2|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1,568.75||||||| 94664|EAP|0410|COLD AERO W-02 CONT MAX 2|Managed Medicare|HOSPICE OF EAST TEXAS|1,568.75||||||| 94664|EAP|0410|SPUTUM INDUCTION|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.98||||||| 94664|EAP|0410|SPUTUM INDUCTION|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|252.25||||1.98||| 94664|EAP|0410|SPUTUM INDUCTION|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.98||||1.98||| 94664|EAP|0410|SPUTUM INDUCTION|Managed Medicaid|MEDICAID AMERIGROUP|1.98||||1.98||| 94664|EAP|0410|SPUTUM INDUCTION|Managed Medicaid|MEDICAID SUPERIOR|1.98||||1.98||| 94664|EAP|0410|COLD AERO W-02 EA TRMT|Managed Medicaid|MEDICAID SUPERIOR|1,568.75||||252.25||| 94667|EAP|0410|PERCUSSION TREATMENT|Managed Medicaid|MEDICAID SUPERIOR|250.50||||||| 94667|EAP|0410|PERCUSSION TREATMENT|Medicare|MEDICARE ACUTE|250.50||||||| 94667|EAP|0410|PERCUSSION TREATMENT|United Medicare Advantage|UHC MEDICARE GOLD MA|250.50||||||| 94667|EAP|0410|PERCUSSION TREATMENT|Humana Medicare Advantage|HUMANA MA|250.50||||||| 94667|EAP|0410|PERCUSSION TREATMENT|Aenta Medicare Advantage|AETNA MEDICARE MA|250.50||||||| 94680|EAP|0460|BREATHING EXER EA TRMT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|320.25||||320.25||| 94680|EAP|0460|BREATHING EXER EA TRMT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|320.25||||||| 94680|EAP|0460|BREATHING EXER EA TRMT|Aetna|AETNA PPO|||||320.25||| 94680|EAP|0460|BREATHING EXER EA TRMT|Blue Cross HMO Specialty|BCBSTX HMO|320.25||||||| 94680|EAP|0460|BREATHING EXER EA TRMT|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|320.25||||||| 94680|EAP|0460|BREATHING EXER EA TRMT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|320.25||||||| 94680|EAP|0460|BREATHING EXER EA TRMT|Cigna|CIGNA|320.25||||||| 94680|EAP|0460|BREATHING EXER EA TRMT|Blue Cross PPO Specialty|BCBSTX PPO|320.25||||320.25||| 94680|EAP|0460|BREATHING EXER EA TRMT|Humana Medicare Advantage|HUMANA MA|320.25||||320.25||| 94680|EAP|0460|BREATHING EXER EA TRMT|United Medicare Advantage|UHC MEDICARE GOLD MA|320.25||||320.25||| 94680|EAP|0460|BREATHING EXER EA TRMT|Workers Compensation|UT EMPLOYEE INJURY|320.25||||||| 94680|EAP|0460|BREATHING EXER EA TRMT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|320.25||||||| 94680|EAP|0460|BREATHING EXER EA TRMT|Blue Cross PPO Specialty|BCBSTX OTHER|320.25||||||| 94680|EAP|0460|BREATHING EXER EA TRMT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|320.25||||||| 94680|EAP|0460|BREATHING EXER EA TRMT|Veterans Affairs|VETERANS ADMINISTRATION|320.25||||320.25||| 94680|EAP|0460|BREATHING EXER EA TRMT|United Medicare Advantage|AARP UHC WEST COMPLETE MA|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 Healthcare|UNITED HEALTHCARE OTHER|320.25||||||| 94680|EAP|0460|BREATHING EXER EA TRMT|United Healthcare|UNITED HEALTHCARE|||||320.25||| 94680|EAP|0460|BREATHING EXER EA TRMT|United Healthcare|UMR UNITED MEDICAL RESOURCES|320.25||||||| 94680|EAP|0460|BREATHING EXER EA TRMT|Workers Compensation|WORKERS COMPENSATION OTHER|320.25||||||| 94680|EAP|0460|BREATHING EXER EA TRMT|Aenta Medicare Advantage|AETNA MEDICARE MA|320.25||||||| 94680|EAP|0460|BREATHING EXER EA TRMT|NON CONTRACTED|COMMERCIAL OTHER 1|320.25||||||| 94680|EAP|0460|BREATHING EXER EA TRMT|Rusk State Hospital|RUSK STATE HOSP|320.25||||||| 94680|EAP|0460|BREATHING EXER EA TRMT|UTMB|UTMB CORRECTIONAL MANAGED CARE|320.25||||||| 94680|EAP|0460|BREATHING EXER EA TRMT|Medicaid|MEDICAID|320.25||||||| 94680|EAP|0460|BREATHING EXER EA TRMT|Tricare|TRICARE EAST REGION|320.25||||||| 94680|EAP|0460|BREATHING EXER EA TRMT|Medicare|MEDICARE ACUTE|320.25||||320.25||| 94680|EAP|0460|BREATHING EXER EA TRMT|Managed Medicare|HEALTHSPRING MA|320.25||||||| 94680|EAP|0460|BREATHING EXER EA TRMT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|320.25||||320.25||| 94680|EAP|0460|BREATHING EXER EA TRMT|Medicaid|COUNTY INDIGENT HEALTH OTHER|320.25||||||| 94680|EAP|0460|BREATHING EXER EA TRMT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|320.25||||320.25||| 94680|EAP|0460|BREATHING EXER EA TRMT|Managed Medicaid|MEDICAID SUPERIOR|320.25||||||| 947|DRG||SIGNS & SYMPTOMS W MCC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|111,705.85|63758.49|63758.49|63758.49|||| 94760|EAP|0410|OXIMETER EA USE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||574.25||| 94760|EAP|0460|EXERCISE STUDY|Managed Medicare|HEALTHSPRING MA|320.25||||||| 94760|EAP|0410|OXIMETER EA USE|Managed Medicaid|MEDICAID SUPERIOR|574.25||||574.25||| 94760|EAP|0410|OXIMETER EA USE|Managed Medicaid|MEDICAID AMERIGROUP|574.25||||574.25||| 94760|EAP|0410|OXIMETER EA USE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|574.25||||574.25||| 94760|EAP|0460|OXIMETER SPOT CHECK EA|Managed Medicaid|MEDICAID SUPERIOR|320.25||||60.75||| 94760|EAP|0460|OXIMETER SPOT CHECK EA|Managed Medicaid|MEDICAID SUPERIOR|60.75||||60.75||| 94760|EAP|0460|EXERCISE STUDY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|320.25||||||| 94760|EAP|0460|EXERCISE STUDY|Managed Medicaid|MEDICAID AMERIGROUP|320.25||||||| 94760|EAP|0460|EXERCISE STUDY|Medicaid|MEDICAID|320.25||||||| 94760|EAP|0410|OXIMETER EA USE|Rusk State Hospital|RUSK STATE HOSP|||||574.25||| 94760|EAP|0460|OXIMETER SPOT CHECK EA|Rusk State Hospital|RUSK STATE HOSP|60.75||||||| 94760|EAP|0410|OXIMETER EA USE|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||574.25||| 94760|EAP|0410|OXIMETER EA USE|Medicaid|MEDICAID PCCM|||||574.25||| 94760|EAP|0410|OXIMETER EA USE|Medicaid|MEDICAID|574.25||||574.25||| 94760|EAP|0410|OXIMETER EA USE|Medicare|MEDICARE ACUTE|574.25||||574.25||| 94760|EAP|0460|OXIMETER SPOT CHECK EA|Medicare|MEDICARE ACUTE|60.75||||||| 94760|EAP|0410|OXIMETER EA USE|Medicaid|MEDICAID HMO|||||574.25||| 94760|EAP|0460|EXERCISE STUDY|Medicare|MEDICARE ACUTE|320.25||||||| 94760|EAP|0460|EXERCISE STUDY|UTMB|UTMB CORRECTIONAL MANAGED CARE|320.25||||||| 94760|EAP|0460|EXERCISE STUDY|Rusk State Hospital|RUSK STATE HOSP|320.25||||||| 94760|EAP|0410|OXIMETER EA USE|UTMB|UTMB CORRECTIONAL MANAGED CARE|574.25||||574.25||| 94760|EAP|0410|OXIMETER EA USE|United Healthcare|GEHA|||||574.25||| 94760|EAP|0410|OXIMETER EA USE|Workers Compensation|WORKERS COMPENSATION OTHER|574.25||||||| 94760|EAP|0410|OXIMETER EA USE|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|574.25||||||| 94760|EAP|0410|OXIMETER EA USE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|574.25||||574.25||| 94760|EAP|0460|EXERCISE STUDY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|320.25||||||| 94760|EAP|0410|OXIMETER EA USE|United Medicare Advantage|UHC MEDICARE GOLD MA|574.25||||574.25||| 94760|EAP|0410|OXIMETER EA USE|Tricare|TRICARE EAST REGION|||||574.25||| 94760|EAP|0410|OXIMETER EA USE|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||574.25||| 94760|EAP|0410|OXIMETER EA USE|NON CONTRACTED|COMMERCIAL OTHER 1|574.25||||574.25||| 94760|EAP|0460|EXERCISE STUDY|United Medicare Advantage|AARP UHC WEST COMPLETE MA|320.25||||||| 94760|EAP|0410|OXIMETER EA USE|United Healthcare|UNITED HEALTHCARE|||||574.25||| 94760|EAP|0460|EXERCISE STUDY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|320.25||||||| 94760|EAP|0460|EXERCISE STUDY|United Healthcare|UNITED HEALTHCARE|320.25||||||| 94760|EAP|0410|OXIMETER EA USE|United Healthcare|UNITED HEALTHCARE|574.25||||||| 94760|EAP|0410|OXIMETER EA USE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|574.25||||574.25||| 94760|EAP|0460|EXERCISE STUDY|Workers Compensation|WORKERS COMPENSATION OTHER|320.25||||||| 94760|EAP|0410|OXIMETER EA USE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|574.25||||574.25||| 94760|EAP|0410|OXIMETER EA USE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|574.25||||574.25||| 94760|EAP|0410|OXIMETER EA USE|Aenta Medicare Advantage|AETNA MEDICARE MA|574.25||||574.25||| 94760|EAP|0460|EXERCISE STUDY|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|320.25||||||| 94760|EAP|0410|OXIMETER EA USE|Managed Medicare|HOSPICE OF EAST TEXAS|574.25||||||| 94760|EAP|0410|OXIMETER EA USE|Blue Cross HMO Specialty|BCBSTX HMO|574.25||||574.25||| 94760|EAP|0460|EXERCISE STUDY|Blue Cross HMO Specialty|BCBSTX HMO|320.25||||||| 94760|EAP|0460|EXERCISE STUDY|Aetna|AETNA PPO|||||320.25||| 94760|EAP|0410|OXIMETER EA USE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||574.25||| 94760|EAP|0410|OXIMETER EA USE|Blue Cross PPO Specialty|BCBSTX PPO|574.25||||574.25||| 94760|EAP|0410|OXIMETER EA USE|Blue Cross PPO Specialty|BCBSTX OTHER|574.25||||574.25||| 94760|EAP|0460|EXERCISE STUDY|Blue Cross PPO Specialty|BCBSTX PPO|320.25||||||| 94760|EAP|0410|OXIMETER EA USE|Humana Medicare Advantage|HUMANA MA|574.25||||574.25||| 94760|EAP|0460|OXIMETER SPOT CHECK EA|Humana Medicare Advantage|HUMANA MA|60.75||||320.25||| 94760|EAP|0460|EXERCISE STUDY|Humana Medicare Advantage|HUMANA MA|320.25||||320.25||| 94760|EAP|0410|OXIMETER EA USE|Cigna|CIGNA|574.25||||574.25||| 94761|EAP|0460|OXIMETER|Blue Cross PPO Specialty|BCBSTX PPO|||||248.75||| 94761|EAP|0460|OXIMETER|Humana Medicare Advantage|HUMANA MA|248.75||||248.75||| 94761|EAP|0460|OXIMETER|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|248.75||||||| 94761|EAP|0460|OXIMETER|Blue Cross HMO Specialty|BCBSTX HMO|||||248.75||| 94761|EAP|0460|OXIMETER|United Medicare Advantage|UHC MEDICARE GOLD MA|248.75||||||| 94761|EAP|0460|OXIMETER|Veterans Affairs|VETERANS ADMINISTRATION|||||248.75||| 94761|EAP|0460|OXIMETER|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||248.75||| 94761|EAP|0460|OXIMETER|United Healthcare|UNITED HEALTHCARE|248.75||||||| 94761|EAP|0460|OXIMETER|Medicare|MEDICARE ACUTE|248.75||||248.75||| 94761|EAP|0460|OXIMETER|UTMB|UTMB CORRECTIONAL MANAGED CARE|248.75||||||| 94761|EAP|0460|OXIMETER|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||248.75||| 94761|EAP|0460|OXIMETER|Managed Medicaid|MEDICAID SUPERIOR|248.75||||||| 94761|EAP|0460|OXIMETER|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||248.75||| 94761|EAP|0460|OXIMETER|Managed Medicaid|MEDICAID AMERIGROUP|||||248.75||| 948|DRG||SIGNS & SYMPTOMS W/O MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|30,715.25|8911.96|8911.96|8266.88|||| 948|DRG||SIGNS & SYMPTOMS W/O MCC|Humana Medicare Advantage|HUMANA MA|34,766.15|8266.88|8911.96|8266.88|||| 95|DRG||BACTERIAL & TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM W CC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|26,758.75|26758.75|26758.75|26758.75|||| 9500034|ERX|0250|ACETAM-COD 120-12MG/5ML E|United Healthcare|UNITED HEALTHCARE|||||11.25||| 9500034|ERX|0250|ACETAM-COD 120-12MG/5ML E|Managed Medicaid|MEDICAID SUPERIOR|11.25||||11.25||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|United Medicare Advantage|UHC MEDICARE GOLD MA|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|Blue Cross HMO Specialty|BCBSTX HMO|0.11||||0.11||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.11||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Blue Cross PPO Specialty|BCBSTX PPO|||||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|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.11||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Managed Medicaid|MEDICAID SUPERIOR|0.11||||0.11||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.11||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Managed Medicaid|MEDICAID AMERIGROUP|||||0.11||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||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 Medicare|HEALTHSPRING MA|0.11||||0.11||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||0.11||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Medicaid|MEDICAID|0.11||||||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Medicare|MEDICARE ACUTE|0.11||||0.11||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|Rusk State Hospital|RUSK STATE HOSP|0.11||||||| 9500125|ERX|0250|MAG-AL HYDROX-SIMETH,30ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||0.11||| 9500141|ERX|0250|GUAI-CODEINE 100-10MG/5ML|Medicare|MEDICARE ACUTE|0.09||||||| 9500141|ERX|0250|GUAI-CODEINE 100-10MG/5ML|Humana Medicare Advantage|HUMANA MA|0.09||||||| 9500141|ERX|0250|GUAI-CODEINE 100-10MG/5ML|Medicaid|MEDICAID|||||0.09||| 9500158|ERX|0250|RANITIDINE 150MG/10ML|Managed Medicaid|MEDICAID SUPERIOR|||||0.58||| 9500174|ERX|0250|GLYCERIN SUPP|Medicaid|MOLINA HEALTHCARE OF TEXAS|2.50||||||| 9500232|ERX|0250|NICOTINE POLACRILEX 2MG G|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||8.50||| 9500349|ERX|0250|FLUMAZENIL 0.5MG/5ML|Humana Medicare Advantage|HUMANA MA|818.50||||||| 9500364|ERX|0250|NITROFURANTOIN MONO 100MG|Medicare|MEDICARE ACUTE|27.25||||27.25||| 9500364|ERX|0250|NITROFURANTOIN MONO 100MG|Medicaid|MEDICAID|||||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|United Medicare Advantage|UHC MEDICARE GOLD MA|||||27.25||| 9500364|ERX|0250|NITROFURANTOIN MONO 100MG|Blue Cross HMO Specialty|BCBSTX HMO|||||27.25||| 9500364|ERX|0250|NITROFURANTOIN MONO 100MG|Blue Cross PPO Specialty|BCBSTX PPO|27.25||||||| 9500364|ERX|0250|NITROFURANTOIN MONO 100MG|Humana Medicare Advantage|HUMANA MA|||||27.25||| 9500364|ERX|0250|NITROFURANTOIN MONO 100MG|Managed Medicaid|MEDICAID SUPERIOR|27.25||||27.25||| 9500364|ERX|0250|NITROFURANTOIN MONO 100MG|Managed Medicaid|MEDICAID AMERIGROUP|||||27.25||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Brinson Benefits|THE HEALTH PLAN SMITH CO|0.05||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|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|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.05||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Aetna|AETNA OTHER|0.05||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Blue Cross PPO Specialty|BCBSTX PPO|0.05||||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 PPO Specialty|BCBSTX OTHER|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|Humana Medicare Advantage|HUMANA MA|0.05||||0.05||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.05||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.05||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Veterans Affairs|VETERANS ADMINISTRATION|0.05||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|0.05||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Medicaid|MEDICAID|0.05||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Medicare|MEDICARE PART B ONLY IP|0.05||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|UTMB|UTMB CORRECTIONAL MANAGED CARE|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|MEDICARE ADVANTAGE OTHER MA|0.05||||||| 9500398|ERX|0250|MAGNESIUM OXIDE 400MG TAB|Managed Medicare|HEALTHSPRING MA|0.05||||||| 9500406|ERX|0250|TRIAMCINOLONE ACET 0.1% ,|Medicare|MEDICARE ACUTE|42.50||||||| 9500406|ERX|0250|TRIAMCINOLONE ACET 0.1% ,|Medicaid|MEDICAID|42.50||||||| 9500406|ERX|0250|TRIAMCINOLONE ACET 0.1% ,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|42.50||||||| 9500406|ERX|0250|TRIAMCINOLONE ACET 0.1% ,|Humana Medicare Advantage|HUMANA MA|42.50||||||| 9500414|ERX|0250|TRIAMCINOLONE ACET 0.1% ,|Humana Medicare Advantage|HUMANA MA|42.50||||||| 9500422|ERX|0250|NYSTATIN OINT, 15 GM|United Medicare Advantage|UHC MEDICARE GOLD MA|35.50||||||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Managed Medicare|BCBS MEDICARE PPO MA|||||34.25||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Managed Medicare|HEALTHSPRING MA|34.25||||||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|United Healthcare|UNITED HEALTHCARE OTHER|||||34.25||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|United Healthcare|UNITED HEALTHCARE|||||34.25||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||34.25||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Aenta Medicare Advantage|AETNA MEDICARE MA|||||34.25||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Blue Cross HMO Specialty|BCBSTX HMO|||||34.25||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||34.25||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Blue Cross PPO Specialty|BCBSTX PPO|34.25||||34.25||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||34.25||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Humana Medicare Advantage|HUMANA MA|||||34.25||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Managed Medicaid|MEDICAID SUPERIOR|34.25||||34.25||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||34.25||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|34.25||||||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Medicare|MEDICARE ACUTE|||||34.25||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Managed Medicaid|MEDICAID AMERIGROUP|||||34.25||| 9500430|ERX|0250|BACITRACIN OINT, 15 GM|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||34.25||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Managed Medicaid|MEDICAID SUPERIOR|9.50||||9.50||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||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|United Medicare Advantage|UHC MEDICARE GOLD MA|||||9.50||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Workers Compensation|UT EMPLOYEE INJURY|||||9.50||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Humana Medicare Advantage|HUMANA MA|||||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|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||9.50||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Access Direct Platinum|HEALTHFIRST TPA UMR|||||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|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||9.50||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||9.50||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Blue Cross PPO Specialty|BCBSTX PPO|||||9.50||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Blue Cross PPO Specialty|BCBSTX 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|Medicare|MEDICARE ACUTE|||||9.50||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|United Healthcare|UNITED HEALTHCARE|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|Tricare|TRICARE EAST REGION|||||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|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||9.50||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Managed Medicare|HEALTHSPRING MA|9.50||||||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Medicaid|MEDICAID TEXAS CHILDRENS|||||9.50||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Medicaid|MEDICAID PCCM|||||9.50||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Medicaid|MEDICAID HMO|||||9.50||| 9500448|ERX|0250|NEOMY-BACITRA-POLYMX UD P|Medicaid|MEDICAID|||||9.50||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Medicaid|MEDICAID TEXAS CHILDRENS|||||44.50||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Medicaid|MEDICAID|44.50||||44.50||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||44.50||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Medicare|MEDICARE ACUTE|||||44.50||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|United Healthcare|UNITED HEALTHCARE|44.50||||||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|United Healthcare|UNITED HEALTHCARE OTHER|44.50||||44.50||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Blue Cross PPO Specialty|BCBSTX PPO|44.50||||||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||44.50||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Managed Medicaid|MEDICAID SUPERIOR|44.50||||44.50||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Cigna|CIGNA|44.50||||||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Managed Medicaid|MEDICAID AMERIGROUP|44.50||||44.50||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Blue Cross HMO Specialty|BCBSTX HMO|44.50||||44.50||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|44.50||||||| 9500455|ERX|0250|NEOMY-BACITRAC-POLYMYX ,1|United Healthcare|UNITED HEALTHCARE|||||44.50||| 9500539|ERX|0250|NEOMYC-BACITR-POLYMYX ,3.|Managed Medicaid|MEDICAID SUPERIOR|0.99||||||| 9500588|ERX|0250|LANOLIN OINT, 30G|Tricare|TRICARE EAST REGION|0.29||||||| 9500588|ERX|0250|LANOLIN OINT, 30G|NON CONTRACTED|COMMERCIAL OTHER 1|0.29||||||| 9500588|ERX|0250|LANOLIN OINT, 30G|United Healthcare|UNITED HEALTHCARE OTHER|0.29||||||| 9500588|ERX|0250|LANOLIN OINT, 30G|United Healthcare|UNITED HEALTHCARE|0.29||||||| 9500588|ERX|0250|LANOLIN OINT, 30G|Medicaid|MEDICAID|0.29||||||| 9500588|ERX|0250|LANOLIN OINT, 30G|Blue Cross HMO Specialty|BCBSTX HMO|0.29||||||| 9500588|ERX|0250|LANOLIN OINT, 30G|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.29||||||| 9500588|ERX|0250|LANOLIN OINT, 30G|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.29||||||| 9500588|ERX|0250|LANOLIN OINT, 30G|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.29||||||| 9500588|ERX|0250|LANOLIN OINT, 30G|Blue Cross PPO Specialty|BCBSTX PPO|0.29||||||| 9500588|ERX|0250|LANOLIN OINT, 30G|Managed Medicaid|MEDICAID AMERIGROUP|0.29||||||| 9500588|ERX|0250|LANOLIN OINT, 30G|Managed Medicaid|MEDICAID SUPERIOR|0.29||||||| 9500588|ERX|0250|LANOLIN OINT, 30G|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.29||||||| 9500588|ERX|0250|LANOLIN OINT, 30G|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.29||||||| 9500612|ERX|0250|ZINC OXIDE 20% OINT, 30 G|Managed Medicaid|MEDICAID SUPERIOR|14.50||||||| 9500612|ERX|0250|ZINC OXIDE 20% OINT, 30 G|Managed Medicaid|MEDICAID UNITED HEALTHCARE|14.50||||||| 9500612|ERX|0250|ZINC OXIDE 20% OINT, 30 G|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|14.50||||||| 9500612|ERX|0250|ZINC OXIDE 20% OINT, 30 G|Medicare|MEDICARE ACUTE|14.50||||||| 9500612|ERX|0250|ZINC OXIDE 20% OINT, 30 G|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||14.50||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Medicaid|MEDICAID|108.25||||108.25||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Medicaid|SUPERIOR HEALTHPLAN CHIP|108.25||||108.25||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|United Healthcare|UNITED HEALTHCARE OTHER|108.25||||108.25||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Medicare|MEDICARE ACUTE|||||108.25||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Tricare|TRICARE EAST REGION|108.25||||||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|United Healthcare|UNITED HEALTHCARE|108.25||||108.25||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Workers Compensation|WORKERS COMPENSATION OTHER|||||108.25||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Medicaid|MOLINA HEALTHCARE OF TEXAS|108.25||||||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|108.25||||||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Blue Cross HMO Specialty|BCBSTX HMO|108.25||||||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|108.25||||||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|108.25||||||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Blue Cross PPO Specialty|BCBSTX PPO|108.25||||108.25||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Managed Medicaid|MEDICAID AMERIGROUP|108.25||||108.25||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Cigna|CIGNA|108.25||||||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Managed Medicaid|MEDICAID UNITED HEALTHCARE|108.25||||||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Managed Medicaid|MEDICAID SUPERIOR|108.25||||108.25||| 9500620|ERX|0250|ERYTHROMYCIN EYE OINT, 3.|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|108.25||||||| 9500687|ERX|0250|LUBRICANT EYE OINTMENT, 3|Medicare|MEDICARE ACUTE|45.25||||||| 9500737|ERX|0250|POLYCARBOPHIL 625MG TABLE|Medicare|MEDICARE ACUTE|2.75||||||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Humana Medicare Advantage|HUMANA MA|9.50||||9.50||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.50||||||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||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 HMO Specialty|BCBSTX HMO|||||9.50||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Aenta Medicare Advantage|AETNA MEDICARE MA|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|Veterans Affairs|VETERANS ADMINISTRATION|9.50||||9.50||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|9.50||||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|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||9.50||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||9.50||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|NON CONTRACTED|COMMERCIAL OTHER 2|||||9.50||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|NON CONTRACTED|COMMERCIAL OTHER 1|9.50||||||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Medicare|MEDICARE PART B ONLY IP|9.50||||||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|Medicare|MEDICARE ACUTE|9.50||||9.50||| 9500760|ERX|0250|NITROGLYCERIN 1 INCH PACK|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||9.50||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Humana Medicare Advantage|HUMANA MA|41.75||||41.75||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|41.75||||||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|41.75||||||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|41.75||||||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|41.75||||||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||41.75||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Medicare|MEDICARE ACUTE|41.75||||41.75||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Medicare|MEDICARE PART B ONLY IP|41.75||||||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Rusk State Hospital|RUSK STATE HOSP|41.75||||||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|UTMB|UTMB CORRECTIONAL MANAGED CARE|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||||||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|||||41.75||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|41.75||||||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||41.75||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Blue Cross PPO Specialty|BCBSTX OTHER|||||41.75||| 9500810|ERX|0250|DULOXETINE 30MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|41.75||||||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.15||||0.15||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|||||0.15||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.15||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.15||||||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Humana Medicare Advantage|HUMANA MA|0.15||||0.15||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.15||||||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.15||||0.15||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.15||||||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.15||||||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Workers Compensation|UT EMPLOYEE INJURY|0.15||||||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.15||||||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Medicare|MEDICARE ACUTE|0.15||||0.15||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.15||||||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|0.15||||||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.15||||||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.15||||||| 9500893|ERX|0250|LISINOPRIL 10MG TABLET|Managed Medicare|HEALTHSPRING MA|0.15||||||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Medicaid|MEDICAID|||||24.50||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Medicare|MEDICARE PART B ONLY IP|24.50||||||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Medicare|MEDICARE ACUTE|24.50||||24.50||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|24.50||||||| 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||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|24.50||||||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|24.50||||24.50||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Humana Medicare Advantage|HUMANA MA|24.50||||24.50||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|24.50||||||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|24.50||||||| 9500901|ERX|0250|CITALOPRAM 20MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|24.50||||||| 9501016|ERX|0250|BUPROPION SR 150MG TABLET|Humana Medicare Advantage|HUMANA MA|||||36.75||| 9501016|ERX|0250|BUPROPION SR 150MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|36.75||||||| 9501024|ERX|0250|BUPROPION 75MG TABLET|Medicare|MEDICARE ACUTE|24.50||||||| 9501024|ERX|0250|BUPROPION 75MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|24.50||||||| 9501032|ERX|0250|BUPROPION 100MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.30||||||| 9501032|ERX|0250|BUPROPION 100MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.30||||||| 9501065|ERX|0250|DIGOXIN 125MCG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.07||||||| 9501065|ERX|0250|DIGOXIN 125MCG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.07||||||| 9501065|ERX|0250|DIGOXIN 125MCG TABLET|Medicare|MEDICARE ACUTE|0.07||||0.07||| 9501065|ERX|0250|DIGOXIN 125MCG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||0.07||| 9501065|ERX|0250|DIGOXIN 125MCG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.07||||||| 9501065|ERX|0250|DIGOXIN 125MCG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.07||||||| 9501065|ERX|0250|DIGOXIN 125MCG TABLET|Humana Medicare Advantage|HUMANA MA|0.07||||0.07||| 9501065|ERX|0250|DIGOXIN 125MCG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.07||||||| 9501206|ERX|0250|SUMATRIPTAN 6MG/0.5ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||819.75||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|NON CONTRACTED|COMMERCIAL OTHER 1|5.16||||||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Medicare|MEDICARE ACUTE|5.16||||5.16||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Rusk State Hospital|RUSK STATE HOSP|5.16||||||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|United Medicare Advantage|UHC MEDICARE GOLD MA|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,|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,|Blue Cross HMO Specialty|BCBSTX HMO|5.16||||||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Aenta Medicare Advantage|AETNA MEDICARE MA|5.16||||||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|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 AMERIGROUP|5.16||||||| 9501214|ERX|0250|FLUTICASONE 0.05% NASAL,|Humana Medicare Advantage|HUMANA MA|5.16||||5.16||| 9501222|ERX|0250|LAMIVUDINE 150MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.66||||||| 9501255|ERX|0250|LAMOTRIGINE 25MG TABLET|Medicare|MEDICARE ACUTE|47.75||||47.75||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Cigna|CIGNA|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Humana Medicare Advantage|HUMANA MA|8.80||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Managed Medicaid|MEDICAID AMERIGROUP|8.80||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Managed Medicaid|MEDICAID SUPERIOR|8.80||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||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 HMO Specialty|BCBSTX HMO|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Aetna|AETNA PPO|||||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|Blue Cross PPO Specialty|BCBSTX OTHER|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|8.80||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8.80||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||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|United Medicare Advantage|AARP UHC WEST COMPLETE MA|8.80||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Workers Compensation|WORKERS COMPENSATION OTHER|8.80||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Veterans Affairs|VETERANS ADMINISTRATION|||||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|Medicaid|MEDICAID|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Medicaid|MEDICAID TEXAS CHILDRENS|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|NON CONTRACTED|COMMERCIAL OTHER 1|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Medicare|MEDICARE ACUTE|8.80||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|United Healthcare|UNITED HEALTHCARE OTHER|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Rusk State Hospital|RUSK STATE HOSP|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|Medicaid Out of State|MEDICAID LOUISIANA|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|United Healthcare|UMR UNITED MEDICAL RESOURCES|8.80||||8.80||| 9501289|ERX|0250|ONDANSETRON ODT 4MG TABLE|United Healthcare|UNITED HEALTHCARE|||||8.80||| 9501305|ERX|0250|LAMOTRIGINE 100MG TABLET|Medicare|MEDICARE ACUTE|52.25||||52.25||| 9501305|ERX|0250|LAMOTRIGINE 100MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|||||52.25||| 9501305|ERX|0250|LAMOTRIGINE 100MG TABLET|Humana Medicare Advantage|HUMANA MA|||||52.25||| 9501305|ERX|0250|LAMOTRIGINE 100MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|||||52.25||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Blue Cross HMO Specialty|BCBSTX HMO|271.40||||271.40||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Blue Cross PPO Specialty|BCBSTX PPO|||||271.40||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Blue Cross PPO Specialty|BCBSTX OTHER|||||271.40||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||271.40||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||271.40||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||271.40||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Managed Medicaid|MEDICAID AMERIGROUP|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|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|271.40||||271.40||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Cigna|CIGNA|||||271.40||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Managed Medicaid|MEDICAID SUPERIOR|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|United Medicare Advantage|UHC MEDICARE GOLD MA|||||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 DUAL COMPLETE HMO SNP MA|||||271.40||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Workers Compensation|WORKERS COMPENSATION OTHER|271.40||||||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Managed Medicare|WELLCARE CHOICE MA|||||271.40||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Medicaid|MEDICAID|271.40||||271.40||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||271.40||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||271.40||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Rusk State Hospital|RUSK STATE HOSP|271.40||||271.40||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Medicare|MEDICARE ACUTE|271.40||||271.40||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||271.40||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|UTMB|UTMB CORRECTIONAL MANAGED CARE|271.40||||271.40||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|United Healthcare|UNITED HEALTHCARE OTHER|||||271.40||| 9501354|ERX|0250|ALBUTEROL INHALER, 8G|United Healthcare|UNITED HEALTHCARE|||||271.40||| 9501412|ERX|0250|DUTASTERIDE 0.5MG CAPSULE|Medicare|MEDICARE ACUTE|35.50||||35.50||| 9501412|ERX|0250|DUTASTERIDE 0.5MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|35.50||||||| 9501438|ERX|0250|PHYTONADIONE 5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|24.50||||||| 9501438|ERX|0250|PHYTONADIONE 5MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|24.50||||||| 9501438|ERX|0250|PHYTONADIONE 5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|24.50||||||| 9501438|ERX|0250|PHYTONADIONE 5MG TABLET|Humana Medicare Advantage|HUMANA MA|24.50||||||| 9501438|ERX|0250|PHYTONADIONE 5MG TABLET|Medicare|MEDICARE ACUTE|24.50||||||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|Medicare|MEDICARE ACUTE|52.50||||||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|United Healthcare|UMR UNITED MEDICAL RESOURCES|52.50||||||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|Rusk State Hospital|RUSK STATE HOSP|52.50||||||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||52.50||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|52.50||||||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|52.50||||||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|Humana Medicare Advantage|HUMANA MA|52.50||||||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|52.50||||||| 9501453|ERX|0250|BUPROPION XL 150MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|52.50||||||| 9501487|ERX|0250|SUMATRIPTAN 50MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|252.25||||||| 9501487|ERX|0250|SUMATRIPTAN 50MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|252.25||||||| 9501511|ERX|0250|VALACYCLOVIR 500MG TABLET|Medicare|MEDICARE ACUTE|69.50||||69.50||| 9501511|ERX|0250|VALACYCLOVIR 500MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||69.50||| 9501511|ERX|0250|VALACYCLOVIR 500MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|69.50||||||| 9501511|ERX|0250|VALACYCLOVIR 500MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|69.50||||||| 9501560|ERX|0250|ACYCLOVIR 200MG CAPSULE|Brinson Benefits|THE HEALTH PLAN SMITH CO|28.75||||||| 9501560|ERX|0250|ACYCLOVIR 200MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|||||28.75||| 9501578|ERX|0250|METHYL SALIC/MENTHOL CRM,|Medicare|MEDICARE ACUTE|0.61||||||| 9501578|ERX|0250|METHYL SALIC/MENTHOL CRM,|Humana Medicare Advantage|HUMANA MA|0.61||||||| 9501602|ERX|0250|FINASTERIDE 5MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|34.25||||||| 9501602|ERX|0250|FINASTERIDE 5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|34.25||||||| 9501602|ERX|0250|FINASTERIDE 5MG TABLET|Humana Medicare Advantage|HUMANA MA|34.25||||34.25||| 9501602|ERX|0250|FINASTERIDE 5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|34.25||||||| 9501602|ERX|0250|FINASTERIDE 5MG TABLET|Managed Medicare|HEALTHSPRING MA|34.25||||||| 9501602|ERX|0250|FINASTERIDE 5MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||34.25||| 9501602|ERX|0250|FINASTERIDE 5MG TABLET|Medicare|MEDICARE ACUTE|34.25||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Medicare|MEDICARE ACUTE|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Managed Medicare|HEALTHSPRING MA|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Medicaid|MEDICAID|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Humana Medicare Advantage|HUMANA MA|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||||| 9501669|ERX|0250|THIAMINE 100MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Workers Compensation|UT EMPLOYEE INJURY|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Blue Cross HMO Specialty|BCBSTX HMO|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Aetna|AETNA PPO|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|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Brinson Benefits|THE HEALTH PLAN SMITH CO|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Humana Medicare Advantage|HUMANA MA|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Medicaid|MEDICAID|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|Rusk State Hospital|RUSK STATE HOSP|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|United Healthcare|UNITED HEALTHCARE|2.50||||||| 9501685|ERX|0250|ASCORBIC ACID 500MG TABLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.50||||||| 9501701|ERX|0250|VITAMIN E 400 UNIT CAPSUL|Medicare|MEDICARE ACUTE|2.50||||||| 9501701|ERX|0250|VITAMIN E 400 UNIT CAPSUL|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.50||||||| 9501701|ERX|0250|VITAMIN E 400 UNIT CAPSUL|Brinson Benefits|THE HEALTH PLAN SMITH CO|2.50||||||| 9501701|ERX|0250|VITAMIN E 400 UNIT CAPSUL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||||| 9501719|ERX|0250|SITAGLIPTIN 50MG TABLET|Humana Medicare Advantage|HUMANA MA|62.25||||||| 9501719|ERX|0250|SITAGLIPTIN 50MG TABLET|Medicare|MEDICARE ACUTE|62.25||||||| 9501727|ERX|0250|PYRIDOXINE 50MG TABLET|Medicaid|MEDICAID|2.50||||2.50||| 9501727|ERX|0250|PYRIDOXINE 50MG TABLET|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||2.50||| 9501727|ERX|0250|PYRIDOXINE 50MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||2.50||| 9501727|ERX|0250|PYRIDOXINE 50MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|||||2.50||| 9501727|ERX|0250|PYRIDOXINE 50MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|2.50||||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|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|United Healthcare|UNITED HEALTHCARE|2.50||||||| 9501768|ERX|0250|ASPIRIN EC 325MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.50||||||| 9501776|ERX|0250|ISOSORBIDE DINITRATE 10MG|Medicare|MEDICARE ACUTE|0.04||||||| 9501776|ERX|0250|ISOSORBIDE DINITRATE 10MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.04||||||| 9501784|ERX|0250|ISOSORBIDE DINITRATE 5MG|Medicare|MEDICARE ACUTE|2.75||||||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|6.50||||||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||6.50||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Humana Medicare Advantage|HUMANA MA|6.50||||6.50||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|6.50||||||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6.50||||||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|6.50||||||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|6.50||||||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|6.50||||||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Medicaid|MEDICAID|6.50||||||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|Medicare|MEDICARE ACUTE|6.50||||6.50||| 9501792|ERX|0250|HYDRALAZINE 25MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|6.50||||6.50||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|40.25||||||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Medicare|MEDICARE PART B ONLY IP|40.25||||||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Managed Medicare|HEALTHSPRING MA|40.25||||||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Medicaid|MEDICAID|40.25||||||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Medicare|MEDICARE ACUTE|40.25||||40.25||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|40.25||||40.25||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|40.25||||||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|40.25||||||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|40.25||||40.25||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Humana Medicare Advantage|HUMANA MA|40.25||||40.25||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|40.25||||||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|40.25||||||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|40.25||||||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|40.25||||40.25||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|40.25||||||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|40.25||||40.25||| 9501800|ERX|0250|MONTELUKAST 10MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|40.25||||||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Blue Cross HMO Specialty|BCBSTX HMO|2.75||||2.75||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.75||||||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Blue Cross PPO Specialty|BCBSTX PPO|2.75||||2.75||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Humana Medicare Advantage|HUMANA MA|2.75||||2.75||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|United Medicare Advantage|AARP UHC WEST COMPLETE MA|2.75||||||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.75||||||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|NON CONTRACTED|COMMERCIAL OTHER 2|||||2.75||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|Medicare|MEDICARE ACUTE|2.75||||||| 9501826|ERX|0250|HYDROCHLOROTHIAZIDE 25MG|United Healthcare|UNITED HEALTHCARE OTHER|2.75||||||| 9501883|ERX|0250|CYANOCOBALAMIN 1000MCG TA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.50||||||| 9501883|ERX|0250|CYANOCOBALAMIN 1000MCG TA|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9501883|ERX|0250|CYANOCOBALAMIN 1000MCG TA|Tricare|TRICARE EAST REGION|2.50||||||| 9501883|ERX|0250|CYANOCOBALAMIN 1000MCG TA|United Medicare Advantage|AARP UHC WEST COMPLETE MA|2.50||||||| 9501883|ERX|0250|CYANOCOBALAMIN 1000MCG TA|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|2.50||||||| 9501883|ERX|0250|CYANOCOBALAMIN 1000MCG TA|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 9501883|ERX|0250|CYANOCOBALAMIN 1000MCG TA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||||| 9501883|ERX|0250|CYANOCOBALAMIN 1000MCG TA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.50||||||| 9501883|ERX|0250|CYANOCOBALAMIN 1000MCG TA|Blue Cross HMO Specialty|BCBSTX HMO|2.50||||||| 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 CIGNA HEALTHSPRING|0.09||||||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|Humana Medicare Advantage|HUMANA MA|0.09||||||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.09||||||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|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|Workers Compensation|UT EMPLOYEE INJURY|0.09||||||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|Medicare|MEDICARE ACUTE|0.09||||0.09||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|Rusk State Hospital|RUSK STATE HOSP|0.09||||||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|Tricare|TRICARE EAST REGION|||||0.09||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|United Healthcare|UNITED HEALTHCARE|0.09||||0.09||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.09||||0.09||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|Medicaid|MEDICAID|0.09||||||| 9501909|ERX|0250|DOXYCYCLINE 100MG CAPSULE|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.09||||||| 9501925|ERX|0250|CARBAMAZEPINE 200MG TABLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|7.75||||7.75||| 9501925|ERX|0250|CARBAMAZEPINE 200MG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||7.75||| 9501933|ERX|0250|OXYBUTYNIN 5MG TABLET|Humana Medicare Advantage|HUMANA MA|7.75||||||| 9501933|ERX|0250|OXYBUTYNIN 5MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|7.75||||||| 9501933|ERX|0250|OXYBUTYNIN 5MG TABLET|Medicaid|MEDICAID|7.75||||||| 9501933|ERX|0250|OXYBUTYNIN 5MG TABLET|Medicare|MEDICARE ACUTE|7.75||||7.75||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|||||2.50||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|Medicaid|MEDICAID|||||2.50||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|2.50||||||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2.50||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|2.50||||||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.50||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|||||2.50||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||2.50||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2.50||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|||||2.50||| 9501958|ERX|0250|PREDNISONE 10MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|||||2.50||| 9501982|ERX|0250|THEOPHYLLINE SR 300MG TAB|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|11.50||||||| 9501982|ERX|0250|THEOPHYLLINE SR 300MG TAB|Veterans Affairs|VETERANS ADMINISTRATION|11.50||||||| 9501982|ERX|0250|THEOPHYLLINE SR 300MG TAB|NON CONTRACTED|COMMERCIAL OTHER 1|11.50||||||| 9501982|ERX|0250|THEOPHYLLINE SR 300MG TAB|Medicare|MEDICARE ACUTE|11.50||||||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Tricare|TRICARE EAST REGION|2.50||||||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Medicare|MEDICARE PART B ONLY IP|2.50||||||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.50||||||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|2.50||||||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Medicaid|MEDICAID|||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|2.50||||||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.50||||||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Aetna|AETNA PPO|||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|2.50||||||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||2.50||| 9501990|ERX|0250|ASPIRIN 81MG TABLET|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|2.50||||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|UHC MEDICARE GOLD MA|2.50||||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|Veterans Affairs|VETERANS ADMINISTRATION|||||2.50||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||25.25||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|Humana Medicare Advantage|HUMANA MA|||||25.25||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|Medicare|MEDICARE ACUTE|||||25.25||| 9502006|ERX|0250|OXYMETAZOLINE NASAL,15ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||25.25||| 9502014|ERX|0250|THEOPHYLLINE SR 200MG TAB|NON CONTRACTED|COMMERCIAL OTHER 1|0.09||||||| 9502014|ERX|0250|THEOPHYLLINE SR 200MG TAB|Veterans Affairs|VETERANS ADMINISTRATION|0.09||||||| 9502022|ERX|0250|ACETAMINOPHEN 120MG SUPP|Managed Medicaid|MEDICAID SUPERIOR|6.75||||6.75||| 9502022|ERX|0250|ACETAMINOPHEN 120MG SUPP|United Healthcare|UNITED HEALTHCARE|||||6.75||| 9502063|ERX|0250|BISMUTH SUBSAL 262MG/15ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.50||||||| 9502097|ERX|0250|PROPRANOLOL 20MG TABLET|Medicare|MEDICARE ACUTE|5.50||||||| 9502097|ERX|0250|PROPRANOLOL 20MG TABLET|Rusk State Hospital|RUSK STATE HOSP|5.50||||||| 9502097|ERX|0250|PROPRANOLOL 20MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|5.50||||||| 9502097|ERX|0250|PROPRANOLOL 20MG TABLET|Humana Medicare Advantage|HUMANA MA|5.50||||||| 9502097|ERX|0250|PROPRANOLOL 20MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.50||||||| 9502097|ERX|0250|PROPRANOLOL 20MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|5.50||||5.50||| 9502097|ERX|0250|PROPRANOLOL 20MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||5.50||| 9502097|ERX|0250|PROPRANOLOL 20MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||5.50||| 9502139|ERX|0250|NITROFURANTOIN MACRO 50MG|Medicare|MEDICARE ACUTE|0.15||||||| 9502139|ERX|0250|NITROFURANTOIN MACRO 50MG|United Healthcare|UMR UNITED MEDICAL RESOURCES|0.15||||||| 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|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||2.50||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|United Medicare Advantage|AARP UHC WEST COMPLETE MA|2.50||||2.50||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Blue Cross HMO Specialty|BCBSTX HMO|2.50||||2.50||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Aenta Medicare Advantage|AETNA MEDICARE MA|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|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|Managed Medicaid|MEDICAID SUPERIOR|2.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Medicaid|MEDICAID|2.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|Tricare|TRICARE EAST REGION|2.50||||||| 9502154|ERX|0250|FERROUS SULFATE 325MG TAB|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.50||||2.50||| 9502170|ERX|0250|FOLIC ACID 0.4MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|NON CONTRACTED|COMMERCIAL OTHER 1|2.50||||||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Rusk State Hospital|RUSK STATE HOSP|2.50||||||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|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|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|United Medicare Advantage|UHC MEDICARE GOLD MA|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|Workers Compensation|WORKERS COMPENSATION OTHER|2.50||||||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Workers Compensation|UT EMPLOYEE INJURY|2.50||||||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||2.50||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Aenta Medicare Advantage|AETNA MEDICARE MA|2.50||||||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Blue Cross HMO Specialty|BCBSTX HMO|2.50||||||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Aetna|AETNA PPO|||||2.50||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Humana Medicare Advantage|HUMANA MA|2.50||||||| 9502188|ERX|0250|MULTIVITAMIN W/MINERALS T|Managed Medicaid|MEDICAID SUPERIOR|2.50||||||| 9502212|ERX|0250|CARBAMIDE PEROXIDE DROP,|Managed Medicaid|MEDICAID AMERIGROUP|||||35.25||| 9502212|ERX|0250|CARBAMIDE PEROXIDE DROP,|Managed Medicaid|MEDICAID SUPERIOR|||||35.25||| 9502212|ERX|0250|CARBAMIDE PEROXIDE DROP,|Medicare|MEDICARE ACUTE|35.25||||35.25||| 9502212|ERX|0250|CARBAMIDE PEROXIDE DROP,|Tricare|TRICARE EAST REGION|||||35.25||| 9502253|ERX|0250|ACETAMINOPHEN 325MG SUPP|Medicare|MEDICARE ACUTE|7.75||||||| 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||| 9502261|ERX|0250|EYE WASH, 120ML|Workers Compensation|UT EMPLOYEE INJURY|||||44.50||| 9502261|ERX|0250|EYE WASH, 120ML|Managed Medicaid|MEDICAID AMERIGROUP|||||44.50||| 9502261|ERX|0250|EYE WASH, 120ML|Managed Medicaid|MEDICAID SUPERIOR|||||44.50||| 9502261|ERX|0250|EYE WASH, 120ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||44.50||| 9502261|ERX|0250|EYE WASH, 120ML|Aetna|AETNA PPO|||||44.50||| 9502261|ERX|0250|EYE WASH, 120ML|Blue Cross PPO Specialty|BCBSTX PPO|||||44.50||| 9502261|ERX|0250|EYE WASH, 120ML|Medicaid|MEDICAID|||||44.50||| 9502261|ERX|0250|EYE WASH, 120ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||44.50||| 9502261|ERX|0250|EYE WASH, 120ML|NON CONTRACTED|COMMERCIAL OTHER 2|||||44.50||| 9502261|ERX|0250|EYE WASH, 120ML|United Healthcare|UNITED HEALTHCARE|||||44.50||| 9502261|ERX|0250|EYE WASH, 120ML|Medicare|MEDICARE ACUTE|||||44.50||| 9502261|ERX|0250|EYE WASH, 120ML|Tricare|TRICARE EAST REGION|||||44.50||| 9502261|ERX|0250|EYE WASH, 120ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||44.50||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|Medicare|MEDICARE ACUTE|9.50||||9.50||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|Medicaid|MEDICAID|||||9.50||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9.50||||||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|9.50||||9.50||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|9.50||||||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|9.50||||||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||9.50||| 9502279|ERX|0250|PROMETHAZINE 25MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||9.50||| 9502287|ERX|0250|BISACODYL 5MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||2.50||| 9502287|ERX|0250|BISACODYL 5MG TABLET|Humana Medicare Advantage|HUMANA MA|2.50||||||| 9502287|ERX|0250|BISACODYL 5MG TABLET|Medicare|MEDICARE ACUTE|2.50||||||| 9502287|ERX|0250|BISACODYL 5MG TABLET|Rusk State Hospital|RUSK STATE HOSP|2.50||||||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Medicaid|MEDICAID|0.04||||||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.04||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|NON CONTRACTED|COMMERCIAL OTHER 1|0.04||||||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Medicare|MEDICARE ACUTE|0.04||||||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|0.04||||||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Blue Cross PPO Specialty|BCBSTX PPO|0.04||||||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.04||||||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Blue Cross HMO Specialty|BCBSTX HMO|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|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||0.04||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Cigna|CIGNA|0.04||||||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Humana Medicare Advantage|HUMANA MA|0.04||||||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.04||||||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Managed Medicaid|MEDICAID SUPERIOR|0.04||||||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|Managed Medicaid|MEDICAID AMERIGROUP|0.04||||||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.04||||||| 9502295|ERX|0250|SIMETHICONE CHEWABLE 80MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.04||||||| 9502352|ERX|0250|NABUMETONE 500MG TABLET|Medicare|MEDICARE ACUTE|16.75||||||| 9502378|ERX|0250|HYDROXYZINE PAMOATE 25MG|Managed Medicaid|MEDICAID AMERIGROUP|5.25||||5.25||| 9502378|ERX|0250|HYDROXYZINE PAMOATE 25MG|Managed Medicaid|MEDICAID SUPERIOR|5.25||||||| 9502378|ERX|0250|HYDROXYZINE PAMOATE 25MG|Blue Cross PPO Specialty|BCBSTX PPO|5.25||||||| 9502378|ERX|0250|HYDROXYZINE PAMOATE 25MG|Blue Cross PPO Specialty|BCBSTX OTHER|||||5.25||| 9502378|ERX|0250|HYDROXYZINE PAMOATE 25MG|Medicare|MEDICARE ACUTE|||||5.25||| 9502378|ERX|0250|HYDROXYZINE PAMOATE 25MG|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||5.25||| 9502410|ERX|0250|CHOLESTYRAMINE-SUCROSE 4G|Medicare|MEDICARE ACUTE|33.50||||||| 9502410|ERX|0250|CHOLESTYRAMINE-SUCROSE 4G|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|33.50||||||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Blue Cross PPO Specialty|BCBSTX PPO|||||36.75||| 9502436|ERX|0250|LIDOCAINE 1% MDV 20ML|Humana Medicare Advantage|HUMANA MA|||||36.75||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Managed Medicare|HOSPICE OF EAST TEXAS|36.25||||||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||36.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Medicaid|MEDICAID PCCM|||||36.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Medicaid|MEDICAID|36.25||||36.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Medicaid|MEDICAID TEXAS CHILDRENS|||||36.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Medicaid|MEDICAID HMO|||||36.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||36.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Tricare|TRICARE EAST REGION|||||36.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Rusk State Hospital|RUSK STATE HOSP|||||36.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|United Healthcare|UNITED HEALTHCARE OTHER|36.25||||36.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||36.25||| 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|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||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||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|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|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||36.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Workers Compensation|WORKERS COMPENSATION OTHER|||||36.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Workers Compensation|UT EMPLOYEE INJURY|36.25||||36.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Veterans Affairs|VETERANS ADMINISTRATION|||||36.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Cigna|CIGNA|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|Cigna|CIGNA|||||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 CIGNA HEALTHSPRING|||||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 Medicare|BCBS MEDICARE PPO MA|||||36.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Managed Medicaid|MEDICAID SUPERIOR|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|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||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|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||36.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Access Direct Platinum|HEALTHFIRST TPA UMR|||||36.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Blue Cross HMO Specialty|BCBSTX HMO|36.25||||36.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Aetna|ZZZZZ AETNA|||||36.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Aetna|AETNA OTHER|||||36.25||| 9502501|ERX|0250|LIDOCAINE 1%PF 5ML|Aetna|AETNA PPO|||||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|Blue Cross PPO Specialty|BCBSTX PPO|36.25||||36.25||| 9502527|ERX|0250|LIDOCAINE 4% SOLUTION, 50|Blue Cross PPO Specialty|BCBSTX PPO|||||222.75||| 9502527|ERX|0250|LIDOCAINE 4% SOLUTION, 50|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|222.75||||||| 9502527|ERX|0250|LIDOCAINE 4% SOLUTION, 50|Humana Medicare Advantage|HUMANA MA|222.75||||||| 9502527|ERX|0250|LIDOCAINE 4% SOLUTION, 50|Managed Medicaid|MEDICAID SUPERIOR|||||222.75||| 9502527|ERX|0250|LIDOCAINE 4% SOLUTION, 50|Medicare|MEDICARE ACUTE|||||222.75||| 9502527|ERX|0250|LIDOCAINE 4% SOLUTION, 50|United Healthcare|UNITED HEALTHCARE OTHER|||||222.75||| 9502535|ERX|0250|LIDOCAINE 2% JELLY, 30ML|Medicare|MEDICARE ACUTE|209.75||||||| 9502535|ERX|0250|LIDOCAINE 2% JELLY, 30ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||209.75||| 9502535|ERX|0250|LIDOCAINE 2% JELLY, 30ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|209.75||||||| 9502535|ERX|0250|LIDOCAINE 2% JELLY, 30ML|Humana Medicare Advantage|HUMANA MA|209.75||||||| 9502535|ERX|0250|LIDOCAINE 2% JELLY, 30ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|209.75||||||| 9502535|ERX|0250|LIDOCAINE 2% JELLY, 30ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||209.75||| 9502535|ERX|0250|LIDOCAINE 2% JELLY, 30ML|Blue Cross PPO Specialty|BCBSTX PPO|209.75||||||| 9502584|ERX|0250|ROPIVACAINE 0.2%, 20ML|Blue Cross HMO Specialty|BCBSTX HMO|87.50||||87.50||| 9502584|ERX|0250|ROPIVACAINE 0.2%, 20ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|87.50||||87.50||| 9502584|ERX|0250|ROPIVACAINE 0.2%, 20ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|87.50||||||| 9502584|ERX|0250|ROPIVACAINE 0.2%, 20ML|Blue Cross PPO Specialty|BCBSTX PPO|87.50||||87.50||| 9502584|ERX|0250|ROPIVACAINE 0.2%, 20ML|Humana Medicare Advantage|HUMANA MA|||||87.50||| 9502584|ERX|0250|ROPIVACAINE 0.2%, 20ML|Managed Medicaid|MEDICAID AMERIGROUP|87.50||||||| 9502584|ERX|0250|ROPIVACAINE 0.2%, 20ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||87.50||| 9502584|ERX|0250|ROPIVACAINE 0.2%, 20ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|87.50||||||| 9502584|ERX|0250|ROPIVACAINE 0.2%, 20ML|Managed Medicaid|MEDICAID SUPERIOR|87.50||||||| 9502584|ERX|0250|ROPIVACAINE 0.2%, 20ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||87.50||| 9502584|ERX|0250|ROPIVACAINE 0.2%, 20ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|87.50||||||| 9502584|ERX|0250|ROPIVACAINE 0.2%, 20ML|Medicaid|MEDICAID|87.50||||||| 9502584|ERX|0250|ROPIVACAINE 0.2%, 20ML|NON CONTRACTED|COMMERCIAL OTHER 1|87.50||||||| 9502584|ERX|0250|ROPIVACAINE 0.2%, 20ML|Medicare|MEDICARE ACUTE|||||87.50||| 9502584|ERX|0250|ROPIVACAINE 0.2%, 20ML|United Healthcare|UNITED HEALTHCARE OTHER|87.50||||||| 9502592|ERX|0250|ROPIVACAINE 0.2%, 100ML|NON CONTRACTED|COMMERCIAL OTHER 1|244.25||||||| 9502592|ERX|0250|ROPIVACAINE 0.2%, 100ML|United Healthcare|UNITED HEALTHCARE OTHER|244.25||||||| 9502592|ERX|0250|ROPIVACAINE 0.2%, 100ML|Medicare|MEDICARE ACUTE|||||244.25||| 9502592|ERX|0250|ROPIVACAINE 0.2%, 100ML|United Healthcare|UNITED HEALTHCARE|244.25||||||| 9502592|ERX|0250|ROPIVACAINE 0.2%, 100ML|Tricare|TRICARE EAST REGION|244.25||||||| 9502592|ERX|0250|ROPIVACAINE 0.2%, 100ML|Medicaid|MEDICAID|244.25||||||| 9502592|ERX|0250|ROPIVACAINE 0.2%, 100ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|244.25||||||| 9502592|ERX|0250|ROPIVACAINE 0.2%, 100ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|244.25||||||| 9502592|ERX|0250|ROPIVACAINE 0.2%, 100ML|Managed Medicaid|MEDICAID SUPERIOR|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 UNITED HEALTHCARE|244.25||||||| 9502592|ERX|0250|ROPIVACAINE 0.2%, 100ML|Blue Cross HMO Specialty|BCBSTX HMO|244.25||||||| 9502592|ERX|0250|ROPIVACAINE 0.2%, 100ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|244.25||||||| 9502592|ERX|0250|ROPIVACAINE 0.2%, 100ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|244.25||||||| 9502592|ERX|0250|ROPIVACAINE 0.2%, 100ML|Blue Cross PPO Specialty|BCBSTX PPO|244.25||||||| 9502592|ERX|0250|ROPIVACAINE 0.2%, 100ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|244.25||||||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|165.25||||||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|United Medicare Advantage|UHC MEDICARE GOLD MA|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|Workers Compensation|WORKERS COMPENSATION OTHER|165.25||||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|Blue Cross HMO Specialty|BCBSTX HMO|165.25||||165.25||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|165.25||||165.25||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Aenta Medicare Advantage|AETNA MEDICARE MA|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 PPO Specialty|BCBSTX PPO|165.25||||165.25||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Managed Medicaid|MEDICAID SUPERIOR|165.25||||||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|165.25||||||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|165.25||||||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Cigna|CIGNA|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 CIGNA HEALTHSPRING|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|Managed Medicaid|MEDICAID AMERIGROUP|165.25||||165.25||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Medicaid|MEDICAID|165.25||||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|Medicare|MEDICARE ACUTE|165.25||||165.25||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Tricare|TRICARE EAST REGION|165.25||||||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||165.25||| 9502600|ERX|0250|ROPIVACAINE 0.5%, 30ML|United Healthcare|UNITED HEALTHCARE OTHER|||||165.25||| 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||||||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.15||||||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Humana Medicare Advantage|HUMANA MA|0.15||||||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.15||||||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Managed Medicaid|MEDICAID SUPERIOR|0.15||||||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.15||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Blue Cross HMO Specialty|BCBSTX HMO|||||0.15||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.15||| 9502667|ERX|0250|METOPROLOL SUCCINATE 25MG|Aenta Medicare Advantage|AETNA MEDICARE MA|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|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.15||||||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.15||||||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Blue Cross HMO Specialty|BCBSTX HMO|0.15||||||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Aenta Medicare Advantage|AETNA MEDICARE MA|0.15||||||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||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 UNITED HEALTHCARE|0.15||||||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.15||||||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Managed Medicare|HEALTHSPRING MA|0.15||||||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|NON CONTRACTED|COMMERCIAL OTHER 1|0.15||||||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|Medicare|MEDICARE ACUTE|0.15||||0.15||| 9502675|ERX|0250|METOPROLOL SUCCINATE 50MG|United Healthcare|UMR UNITED MEDICAL RESOURCES|0.15||||||| 9502683|ERX|0250|METOPROLOL SUCCINATE 100M|Medicare|MEDICARE ACUTE|0.20||||||| 9502683|ERX|0250|METOPROLOL SUCCINATE 100M|Humana Medicare Advantage|HUMANA MA|0.20||||||| 9502683|ERX|0250|METOPROLOL SUCCINATE 100M|Blue Cross HMO Specialty|BCBSTX HMO|0.20||||||| 9502683|ERX|0250|METOPROLOL SUCCINATE 100M|Aenta Medicare Advantage|AETNA MEDICARE MA|0.20||||||| 9502683|ERX|0250|METOPROLOL SUCCINATE 100M|Blue Cross PPO Specialty|BCBSTX PPO|||||0.20||| 9502683|ERX|0250|METOPROLOL SUCCINATE 100M|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.20||||||| 9502683|ERX|0250|METOPROLOL SUCCINATE 100M|United Medicare Advantage|UHC MEDICARE GOLD MA|0.20||||||| 9502709|ERX|0250|MORPHINE (PF) 10MG, 10ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||135.75||| 9502709|ERX|0250|MORPHINE (PF) 10MG, 10ML|Blue Cross HMO Specialty|BCBSTX HMO|135.75||||135.75||| 9502709|ERX|0250|MORPHINE (PF) 10MG, 10ML|Aenta Medicare Advantage|AETNA MEDICARE MA|135.75||||||| 9502709|ERX|0250|MORPHINE (PF) 10MG, 10ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|135.75||||||| 9502709|ERX|0250|MORPHINE (PF) 10MG, 10ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|135.75||||||| 9502709|ERX|0250|MORPHINE (PF) 10MG, 10ML|Humana Medicare Advantage|HUMANA MA|135.75||||||| 9502709|ERX|0250|MORPHINE (PF) 10MG, 10ML|Blue Cross PPO Specialty|BCBSTX PPO|135.75||||135.75||| 9502709|ERX|0250|MORPHINE (PF) 10MG, 10ML|Cigna|CIGNA|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 UNITED HEALTHCARE|135.75||||||| 9502709|ERX|0250|MORPHINE (PF) 10MG, 10ML|Managed Medicaid|MEDICAID SUPERIOR|135.75||||||| 9502709|ERX|0250|MORPHINE (PF) 10MG, 10ML|Managed Medicaid|MEDICAID AMERIGROUP|135.75||||||| 9502709|ERX|0250|MORPHINE (PF) 10MG, 10ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|135.75||||||| 9502709|ERX|0250|MORPHINE (PF) 10MG, 10ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||135.75||| 9502709|ERX|0250|MORPHINE (PF) 10MG, 10ML|Medicaid|MEDICAID|135.75||||||| 9502709|ERX|0250|MORPHINE (PF) 10MG, 10ML|NON CONTRACTED|COMMERCIAL OTHER 1|135.75||||||| 9502709|ERX|0250|MORPHINE (PF) 10MG, 10ML|Medicare|MEDICARE ACUTE|135.75||||135.75||| 9502709|ERX|0250|MORPHINE (PF) 10MG, 10ML|United Healthcare|UNITED HEALTHCARE OTHER|135.75||||135.75||| 9502709|ERX|0250|MORPHINE (PF) 10MG, 10ML|United Healthcare|UNITED HEALTHCARE|135.75||||||| 9502709|ERX|0250|MORPHINE (PF) 10MG, 10ML|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|135.75||||||| 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||| 9502725|ERX|0250|LIDOCAINE-PRILOCAINE, 1 K|Managed Medicaid|MEDICAID AMERIGROUP|1.01||||1.01||| 9502725|ERX|0250|LIDOCAINE-PRILOCAINE, 1 K|Managed Medicaid|MEDICAID SUPERIOR|1.01||||1.01||| 9502725|ERX|0250|LIDOCAINE-PRILOCAINE, 1 K|Blue Cross HMO Specialty|BCBSTX HMO|1.01||||||| 9502725|ERX|0250|LIDOCAINE-PRILOCAINE, 1 K|Blue Cross PPO Specialty|BCBSTX PPO|1.01||||||| 9502725|ERX|0250|LIDOCAINE-PRILOCAINE, 1 K|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.01||||||| 9502733|ERX|0250|BUDESONIDE NEB 0.25MG/2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|68.50||||||| 9502733|ERX|0250|BUDESONIDE NEB 0.25MG/2ML|Managed Medicaid|MEDICAID AMERIGROUP|68.50||||||| 9502733|ERX|0250|BUDESONIDE NEB 0.25MG/2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||68.50||| 9502733|ERX|0250|BUDESONIDE NEB 0.25MG/2ML|Humana Medicare Advantage|HUMANA MA|68.50||||68.50||| 9502733|ERX|0250|BUDESONIDE NEB 0.25MG/2ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|68.50||||||| 9502733|ERX|0250|BUDESONIDE NEB 0.25MG/2ML|Medicare|MEDICARE ACUTE|68.50||||||| 9502733|ERX|0250|BUDESONIDE NEB 0.25MG/2ML|Medicaid|MEDICAID|68.50||||||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Medicaid|MEDICAID|69.75||||||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|NON CONTRACTED|COMMERCIAL OTHER 1|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|UTMB|UTMB CORRECTIONAL MANAGED CARE|69.75||||||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Rusk State Hospital|RUSK STATE HOSP|69.75||||||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Aenta Medicare Advantage|AETNA MEDICARE MA|69.75||||||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Blue Cross HMO Specialty|BCBSTX HMO|69.75||||||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Managed Medicare|HEALTHSPRING MA|69.75||||||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Blue Cross PPO Specialty|BCBSTX PPO|||||69.75||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Humana Medicare Advantage|HUMANA MA|69.75||||69.75||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Managed Medicaid|MEDICAID AMERIGROUP|69.75||||||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||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 SUPERIOR|69.75||||69.75||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|69.75||||||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||69.75||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|United Medicare Advantage|UHC MEDICARE GOLD MA|69.75||||||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|69.75||||||| 9502741|ERX|0250|BUDESONIDE NEB 0.5MG/2ML|Workers Compensation|UT EMPLOYEE INJURY|69.75||||||| 9502758|ERX|0250|ESOMEPRAZOLE 40MG PACKET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|41.50||||||| 9502758|ERX|0250|ESOMEPRAZOLE 40MG PACKET|United Medicare Advantage|UHC MEDICARE GOLD MA|41.50||||||| 9502758|ERX|0250|ESOMEPRAZOLE 40MG PACKET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|41.50||||||| 9502758|ERX|0250|ESOMEPRAZOLE 40MG PACKET|Humana Medicare Advantage|HUMANA MA|41.50||||||| 9502758|ERX|0250|ESOMEPRAZOLE 40MG PACKET|Medicare|MEDICARE ACUTE|41.50||||||| 9502758|ERX|0250|ESOMEPRAZOLE 40MG PACKET|UTMB|UTMB CORRECTIONAL MANAGED CARE|41.50||||||| 9502758|ERX|0250|ESOMEPRAZOLE 40MG PACKET|Rusk State Hospital|RUSK STATE HOSP|41.50||||||| 9502774|ERX|0250|ESOMEPRAZOLE 40MG CAPSULE|Medicare|MEDICARE ACUTE|57.75||||57.75||| 9502774|ERX|0250|ESOMEPRAZOLE 40MG CAPSULE|Cigna|CIGNA|||||57.75||| 9502774|ERX|0250|ESOMEPRAZOLE 40MG CAPSULE|Humana Medicare Advantage|HUMANA MA|57.75||||||| 9502774|ERX|0250|ESOMEPRAZOLE 40MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|57.75||||||| 9502774|ERX|0250|ESOMEPRAZOLE 40MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|57.75||||||| 9502774|ERX|0250|ESOMEPRAZOLE 40MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|57.75||||||| 9502808|ERX|0250|DEXTROSE GEL 15 G|Managed Medicaid|MEDICAID AMERIGROUP|26.25||||||| 9502808|ERX|0250|DEXTROSE GEL 15 G|Managed Medicaid|MEDICAID SUPERIOR|26.25||||||| 9502808|ERX|0250|DEXTROSE GEL 15 G|United Healthcare|UNITED HEALTHCARE|26.25||||||| 9502816|ERX|0250|SIMVASTATIN 10MG TABLET|Medicare|MEDICARE ACUTE|12.75||||||| 9502816|ERX|0250|SIMVASTATIN 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|12.75||||||| 9502816|ERX|0250|SIMVASTATIN 10MG TABLET|Humana Medicare Advantage|HUMANA MA|12.75||||||| 9502907|ERX|0250|CHLORDIAZ-CLIDIN 5-2.5MG|Humana Medicare Advantage|HUMANA MA|37.75||||||| 9502949|ERX|0250|PIPERACILLIN-TAZOBACTAM 2|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||148.50||| 9502949|ERX|0250|PIPERACILLIN-TAZOBACTAM 2|Managed Medicaid|MEDICAID SUPERIOR|148.50||||||| 9503046|ERX|0250|SODIUM CHLORIDE 1 G TABLE|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9503046|ERX|0250|SODIUM CHLORIDE 1 G TABLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.50||||||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|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|Veterans Affairs|VETERANS ADMINISTRATION|24.50||||||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|24.50||||||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|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|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|24.50||||||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|24.50||||||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|24.50||||||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|24.50||||||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Humana Medicare Advantage|HUMANA MA|24.50||||24.50||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|24.50||||||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|24.50||||||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|24.50||||||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Medicaid|MEDICAID|24.50||||||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|24.50||||||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|Medicare|MEDICARE ACUTE|24.50||||24.50||| 9503053|ERX|0250|LOSARTAN 50MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|24.50||||||| 9503061|ERX|0250|NIFEDIPINE 10MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|12.50||||||| 9503061|ERX|0250|NIFEDIPINE 10MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|||||12.50||| 9503079|ERX|0250|ISOSORBIDE MONONITRATE 20|Humana Medicare Advantage|HUMANA MA|11.50||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|NON CONTRACTED|COMMERCIAL OTHER 1|4.25||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Rusk State Hospital|RUSK STATE HOSP|4.25||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|United Healthcare|UNITED HEALTHCARE|||||4.25||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Managed Medicare|HEALTHSPRING MA|4.25||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Medicaid|MEDICAID TEXAS CHILDRENS|||||4.25||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Medicaid|MEDICAID|4.25||||4.25||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Medicare|MEDICARE ACUTE|4.25||||4.25||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||4.25||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||4.25||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|4.25||||4.25||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|United Medicare Advantage|UHC MEDICARE GOLD MA|4.25||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4.25||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Blue Cross HMO Specialty|BCBSTX HMO|4.25||||4.25||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.25||||||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||4.25||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Blue Cross PPO Specialty|BCBSTX PPO|4.25||||4.25||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Aenta Medicare Advantage|AETNA MEDICARE MA|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|Cigna|CIGNA|||||4.25||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Managed Medicaid|MEDICAID SUPERIOR|||||4.25||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.25||||4.25||| 9503111|ERX|0250|K CHLORIDE 20 MEQ PACKET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||4.25||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Humana Medicare Advantage|HUMANA MA|5.25||||5.25||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.25||||||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.25||||||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Aetna|AETNA OTHER|5.25||||||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Blue Cross PPO Specialty|BCBSTX OTHER|5.25||||||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Blue Cross PPO Specialty|BCBSTX PPO|5.25||||||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|United Medicare Advantage|UHC MEDICARE GOLD MA|5.25||||||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|United Medicare Advantage|AARP UHC WEST COMPLETE MA|5.25||||||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|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|NON CONTRACTED|COMMERCIAL OTHER 1|5.25||||||| 9503129|ERX|0250|POTASSIUM CHLORIDE 10 MEQ|Medicare|MEDICARE ACUTE|5.25||||5.25||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|NON CONTRACTED|COMMERCIAL OTHER 1|0.09||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Medicare|MEDICARE ACUTE|0.09||||0.09||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|United Healthcare|UNITED HEALTHCARE|0.09||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Rusk State Hospital|RUSK STATE HOSP|0.09||||0.09||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|United Healthcare|UNITED HEALTHCARE OTHER|0.09||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|United Healthcare|UMR UNITED MEDICAL RESOURCES|0.09||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.09||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Managed Medicare|HEALTHSPRING MA|0.09||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Medicaid|MEDICAID TEXAS CHILDRENS|||||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|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|Workers Compensation|UT EMPLOYEE INJURY|0.09||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Workers Compensation|WORKERS COMPENSATION OTHER|0.09||||0.09||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Veterans Affairs|VETERANS ADMINISTRATION|0.09||||0.09||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Medicaid|MEDICAID|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|Aenta Medicare Advantage|AETNA MEDICARE MA|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|Blue Cross PPO Specialty|BCBSTX PPO|0.09||||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|Medicare|MEDICARE PART B ONLY IP|0.09||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Aetna|AETNA OTHER|0.09||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.09||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Blue Cross PPO Specialty|BCBSTX OTHER|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|Brinson Benefits|THE HEALTH PLAN SMITH CO|0.09||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Cigna|CIGNA|0.09||||||| 9503137|ERX|0250|POTASSIUM CHLORIDE 20 MEQ|Cigna|CIGNA|||||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 SUPERIOR|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|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.09||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Humana Medicare Advantage|HUMANA MA|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Brinson Benefits|THE HEALTH PLAN SMITH CO|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Aenta Medicare Advantage|AETNA MEDICARE MA|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Blue Cross HMO Specialty|BCBSTX HMO|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Aetna|AETNA PPO|2.50||||2.50||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Workers Compensation|UT EMPLOYEE INJURY|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Medicare|MEDICARE ACUTE|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|Rusk State Hospital|RUSK STATE HOSP|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|United Healthcare|UNITED HEALTHCARE|2.50||||||| 9503145|ERX|0250|ZINC SULFATE 220MG CAPSUL|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Medicare|MEDICARE ACUTE|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Medicaid|MEDICAID|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||||| 9503152|ERX|0250|MULTIVITAMINS TABLET|Blue Cross PPO Specialty|BCBSTX PPO|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 CIGNA HEALTHSPRING|130.25||||||| 9503202|ERX|0250|NA CHL 0.65% NASAL SPRAY,|Rusk State Hospital|RUSK STATE HOSP|0.38||||||| 9503202|ERX|0250|NA CHL 0.65% NASAL SPRAY,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.38||||||| 9503202|ERX|0250|NA CHL 0.65% NASAL SPRAY,|Blue Cross HMO Specialty|BCBSTX HMO|0.38||||||| 9503202|ERX|0250|NA CHL 0.65% NASAL SPRAY,|Humana Medicare Advantage|HUMANA MA|0.38||||||| 9503244|ERX|0250|CEFOXITIN 2 G VIAL|Managed Medicaid|MEDICAID SUPERIOR|||||2.36||| 9503251|ERX|0250|SODIUM CHLORIDE 3% 500ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.86||||||| 9503251|ERX|0250|SODIUM CHLORIDE 3% 500ML|Humana Medicare Advantage|HUMANA MA|||||0.86||| 9503434|ERX|0250|ANASTROZOLE 1MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|109.25||||||| 9503434|ERX|0250|ANASTROZOLE 1MG TABLET|Medicare|MEDICARE ACUTE|109.25||||||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|Medicare|MEDICARE ACUTE|44.25||||||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|Rusk State Hospital|RUSK STATE HOSP|44.25||||||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||44.25||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|Humana Medicare Advantage|HUMANA MA|44.25||||44.25||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||44.25||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|44.25||||44.25||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|44.25||||||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|Aetna|AETNA OTHER|44.25||||||| 9503459|ERX|0250|QUETIAPINE 100MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|44.25||||||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|25.75||||||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|25.75||||||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|25.75||||25.75||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|25.75||||||| 9503483|ERX|0250|QUETIAPINE 25MG TABLET|Medicare|MEDICARE ACUTE|25.75||||25.75||| 9503517|ERX|0250|MEROPENEM 1 G VIAL|Medicare|MEDICARE ACUTE|682.50||||||| 9503525|ERX|0250|MEROPENEM 500MG VIAL|Medicare|MEDICARE ACUTE|3.79||||||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|37.50||||||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|37.50||||||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|37.50||||||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|Humana Medicare Advantage|HUMANA MA|37.50||||||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|37.50||||||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|37.50||||||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|37.50||||||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|37.50||||37.50||| 9503582|ERX|0250|ROSUVASTATIN 20MG TABLET|Medicare|MEDICARE ACUTE|37.50||||||| 9503590|ERX|0250|ROSUVASTATIN 5MG TABLET|Medicare|MEDICARE ACUTE|37.50||||37.50||| 9503590|ERX|0250|ROSUVASTATIN 5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|37.50||||||| 9503590|ERX|0250|ROSUVASTATIN 5MG TABLET|Humana Medicare Advantage|HUMANA MA|37.50||||||| 9503590|ERX|0250|ROSUVASTATIN 5MG TABLET|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|37.50||||||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Workers Compensation|WORKERS COMPENSATION OTHER|106.25||||||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Blue Cross HMO Specialty|BCBSTX HMO|||||106.25||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Blue Cross PPO Specialty|BCBSTX PPO|106.25||||||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Managed Medicaid|MEDICAID SUPERIOR|106.25||||||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Managed Medicaid|MEDICAID AMERIGROUP|106.25||||||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|NON CONTRACTED|COMMERCIAL OTHER 1|||||106.25||| 9503640|ERX|0258|CEFAZOLIN 1 GM/50ML D5W|Medicare|MEDICARE ACUTE|106.25||||106.25||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|NON CONTRACTED|COMMERCIAL OTHER 1|0.05||||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|UTMB|UTMB CORRECTIONAL MANAGED CARE|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 Medicare|HEALTHSPRING MA|0.05||||||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Medicaid|MEDICAID|0.05||||||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Cigna|CIGNA|||||0.05||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.05||||||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Humana Medicare Advantage|HUMANA MA|0.05||||||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Rusk State Hospital|RUSK STATE HOSP|0.05||||||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|NON CONTRACTED|COMMERCIAL OTHER 2|||||0.05||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.05||||0.05||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Aenta Medicare Advantage|AETNA MEDICARE MA|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 Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.05||||0.05||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Aetna|AETNA OTHER|0.05||||||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Blue Cross PPO Specialty|BCBSTX PPO|0.05||||0.05||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.05||||||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||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|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.05||||||| 9503673|ERX|0250|METOPROLOL TARTRATE 25MG|Veterans Affairs|VETERANS ADMINISTRATION|0.05||||0.05||| 9503780|ERX|0250|TIMOLOL/DORZOLAM DROP,10M|United Medicare Advantage|AARP UHC WEST COMPLETE MA|971.50||||||| 9503848|ERX|0250|GUANFACINE 1MG TABLET|Medicare|MEDICARE ACUTE|0.13||||||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.05||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|||||0.05||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.05||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|Cigna|CIGNA|0.05||||||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|Humana Medicare Advantage|HUMANA MA|0.05||||0.05||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.05||||||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.05||||||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|Blue Cross HMO Specialty|BCBSTX HMO|0.05||||||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.05||||||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|0.05||||||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|0.05||||||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.05||||||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|Veterans Affairs|VETERANS ADMINISTRATION|0.05||||||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|Managed Medicare|HEALTHSPRING MA|0.05||||||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|Medicaid|MEDICAID|0.05||||||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|Rusk State Hospital|RUSK STATE HOSP|0.05||||||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|Medicare|MEDICARE ACUTE|0.05||||0.05||| 9503863|ERX|0250|LEVOTHYROXINE 25MCG TABLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.05||||||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Medicare|MEDICARE ACUTE|5.25||||||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Managed Medicare|HEALTHSPRING MA|5.25||||||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Medicaid|MEDICAID|5.25||||||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|5.25||||||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|United Healthcare|UMR UNITED MEDICAL RESOURCES|5.25||||||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||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|United Medicare Advantage|AARP UHC WEST COMPLETE MA|5.25||||||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Veterans Affairs|VETERANS ADMINISTRATION|5.25||||||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Cigna|CIGNA|5.25||||||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Humana Medicare Advantage|HUMANA MA|5.25||||5.25||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Managed Medicaid|MEDICAID SUPERIOR|5.25||||||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.25||||5.25||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Blue Cross HMO Specialty|BCBSTX HMO|5.25||||5.25||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Blue Cross PPO Specialty|BCBSTX OTHER|5.25||||||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|5.25||||||| 9503889|ERX|0250|LEVOTHYROXINE 75MCG TABLE|Aenta Medicare Advantage|AETNA MEDICARE MA|5.25||||||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Blue Cross HMO Specialty|BCBSTX HMO|5.25||||||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Blue Cross PPO Specialty|BCBSTX OTHER|5.25||||||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Blue Cross PPO Specialty|BCBSTX PPO|5.25||||5.25||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||5.25||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Aenta Medicare Advantage|AETNA MEDICARE MA|5.25||||||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.25||||||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Cigna|CIGNA|5.25||||||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.25||||||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Managed Medicaid|MEDICAID SUPERIOR|5.25||||||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Humana Medicare Advantage|HUMANA MA|5.25||||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|United Medicare Advantage|AARP UHC WEST COMPLETE MA|5.25||||||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|United Medicare Advantage|UHC MEDICARE SOLUTIONS 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|Veterans Affairs|VETERANS ADMINISTRATION|5.25||||||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Medicaid|MEDICAID|5.25||||||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Medicare|MEDICARE ACUTE|5.25||||5.25||| 9503897|ERX|0250|LEVOTHYROXINE 100MCG TABL|Rusk State Hospital|RUSK STATE HOSP|5.25||||||| 9503905|ERX|0250|LEVOTHYROXINE 112MCG TABL|Medicare|MEDICARE ACUTE|6.50||||||| 9503905|ERX|0250|LEVOTHYROXINE 112MCG TABL|Humana Medicare Advantage|HUMANA MA|6.50||||||| 9503913|ERX|0250|LEVOTHYROXINE 125MCG TABL|Managed Medicaid|MEDICAID AMERIGROUP|6.50||||||| 9503913|ERX|0250|LEVOTHYROXINE 125MCG TABL|Managed Medicaid|MEDICAID SUPERIOR|6.50||||||| 9503913|ERX|0250|LEVOTHYROXINE 125MCG TABL|Medicare|MEDICARE ACUTE|6.50||||||| 9503913|ERX|0250|LEVOTHYROXINE 125MCG TABL|Rusk State Hospital|RUSK STATE HOSP|6.50||||||| 9503962|ERX|0250|NITROGLYCERIN 0.2MG PATCH|Medicare|MEDICARE ACUTE|0.20||||||| 9503970|ERX|0250|NITROGLYCERIN 0.4MG PATCH|Medicare|MEDICARE ACUTE|0.23||||||| 9504069|ERX|0250|MORPHINE ER 30MG TABLET|Medicare|MEDICARE ACUTE|0.21||||||| 9504101|ERX|0250|TEMAZEPAM 7.5MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|73.25||||||| 9504101|ERX|0250|TEMAZEPAM 7.5MG CAPSULE|Medicare|MEDICARE ACUTE|73.25||||||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|Managed Medicare|HEALTHSPRING MA|16.50||||||| 9504176|ERX|0250|VERAPAMIL 5MG/2ML|Workers Compensation|WORKERS COMPENSATION OTHER|||||16.50||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Blue Cross HMO Specialty|BCBSTX HMO|12.50||||12.50||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Aetna|AETNA PPO|12.50||||||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Blue Cross PPO Specialty|BCBSTX OTHER|||||12.50||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Blue Cross PPO Specialty|BCBSTX PPO|||||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|Humana Medicare Advantage|HUMANA MA|12.50||||12.50||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Managed Medicaid|MEDICAID AMERIGROUP|12.50||||||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Managed Medicaid|MEDICAID SUPERIOR|12.50||||||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|12.50||||||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Workers Compensation|WORKERS COMPENSATION OTHER|||||12.50||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Medicare|MEDICARE ACUTE|12.50||||12.50||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Tricare|TRICARE EAST REGION|12.50||||||| 9504218|ERX|0250|GENTAMICIN 40MG/ML, 2ML|Medicaid|MEDICAID|||||12.50||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.53||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|Managed Medicare|HEALTHSPRING MA|0.53||||||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||0.53||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|Medicare|MEDICARE ACUTE|0.53||||0.53||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|Rusk State Hospital|RUSK STATE HOSP|0.53||||||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.53||||0.53||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||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 CIGNA HEALTHSPRING|0.53||||0.53||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|Humana Medicare Advantage|HUMANA MA|0.53||||0.53||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.53||||||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|Blue Cross HMO Specialty|BCBSTX HMO|||||0.53||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||0.53||| 9504226|ERX|0250|NALOXONE 0.4MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|0.53||||0.53||| 9504259|ERX|0250|DIAZEPAM 5MG/ML, 2ML|Humana Medicare Advantage|HUMANA MA|||||57.75||| 9504259|ERX|0250|DIAZEPAM 5MG/ML, 2ML|Medicare|MEDICARE ACUTE|57.75||||||| 9504259|ERX|0250|DIAZEPAM 5MG/ML, 2ML|Medicare|MEDICARE PART B ONLY IP|57.75||||||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||16.75||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Managed Medicare|HEALTHSPRING MA|16.75||||||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Medicaid|MEDICAID|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|United Healthcare|UMR UNITED MEDICAL RESOURCES|16.75||||||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|16.75||||||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Tricare|TRICARE EAST REGION|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|AARP UHC WEST COMPLETE MA|16.75||||||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||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|Aenta Medicare Advantage|AETNA MEDICARE MA|||||16.75||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Blue Cross HMO Specialty|BCBSTX HMO|16.75||||16.75||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Aetna|AETNA PPO|16.75||||||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Aetna|AETNA OTHER|||||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 OTHER|||||16.75||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|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 AMERIGROUP|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||||16.75||| 9504267|ERX|0250|HYDROMORPHONE PF 2MG/1ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|16.75||||||| 9504275|ERX|0250|PHENYTOIN 100MG/2ML|Blue Cross PPO Specialty|BCBSTX PPO|0.22||||0.22||| 9504275|ERX|0250|PHENYTOIN 100MG/2ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||0.22||| 9504291|ERX|0250|PHENYTOIN 250MG/5ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||28.50||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||81.50||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Workers Compensation|WORKERS COMPENSATION OTHER|||||81.50||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Humana Medicare Advantage|HUMANA MA|81.50||||81.50||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Managed Medicaid|MEDICAID SUPERIOR|81.50||||||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|81.50||||||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|81.50||||81.50||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Aenta Medicare Advantage|AETNA MEDICARE MA|81.50||||||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|81.50||||81.50||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Blue Cross HMO Specialty|BCBSTX HMO|||||81.50||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|81.50||||||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Medicaid|MEDICAID|||||81.50||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Medicare|MEDICARE ACUTE|81.50||||81.50||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|Rusk State Hospital|RUSK STATE HOSP|81.50||||||| 9504325|ERX|0250|NOREPINEPHRINE 4MG/4ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|81.50||||81.50||| 9504333|ERX|0250|NALBUPHINE 20MG/1ML|Medicare|MEDICARE ACUTE|||||42.75||| 9504333|ERX|0250|NALBUPHINE 20MG/1ML|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||42.75||| 9504333|ERX|0250|NALBUPHINE 20MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|||||42.75||| 9504333|ERX|0250|NALBUPHINE 20MG/1ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|42.75||||||| 9504333|ERX|0250|NALBUPHINE 20MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|||||42.75||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||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|Workers Compensation|WORKERS COMPENSATION OTHER|||||29.50||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||29.50||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Cigna|CIGNA|||||29.50||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Managed Medicaid|MEDICAID SUPERIOR|29.50||||29.50||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||29.50||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Managed Medicaid|MEDICAID AMERIGROUP|29.50||||29.50||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Humana Medicare Advantage|HUMANA MA|29.50||||29.50||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||29.50||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|29.50||||29.50||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Blue Cross PPO Specialty|BCBSTX PPO|||||29.50||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Blue Cross HMO Specialty|BCBSTX HMO|29.50||||29.50||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Access Direct Platinum|HEALTHFIRST TPA UMR|||||29.50||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Aetna|AETNA PPO|29.50||||||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Aetna|AETNA OTHER|||||29.50||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||29.50||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|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 PPO Specialty|BCBSTX OTHER|||||29.50||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Aenta Medicare Advantage|AETNA MEDICARE 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|Medicaid|MEDICAID|||||29.50||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|NON CONTRACTED|COMMERCIAL OTHER 1|29.50||||29.50||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|United Healthcare|UMR UNITED MEDICAL RESOURCES|29.50||||||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|United Healthcare|UNITED HEALTHCARE OTHER|||||29.50||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|Medicare|MEDICARE ACUTE|29.50||||29.50||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|United Healthcare|UNITED HEALTHCARE|29.50||||29.50||| 9504374|ERX|0250|BUPIVACAINE 0.25%PF 10ML|United Healthcare|UNITED HEALTHCARE|29.50||||||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Medicare|MEDICARE ACUTE|34.50||||34.50||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|United Healthcare|UNITED HEALTHCARE OTHER|||||34.50||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Blue Cross HMO Specialty|BCBSTX HMO|||||34.50||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||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|Managed Medicaid|MEDICAID SUPERIOR|||||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 UNITED HEALTHCARE|||||34.50||| 9504382|ERX|0250|BUPIVACAINE 0.25%PF 30ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||34.50||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Managed Medicaid|MEDICAID SUPERIOR|35.50||||||| 9504390|ERX|0250|BUPIVACAINE 0.5%PF 10ML|Blue Cross HMO Specialty|BCBSTX HMO|||||35.50||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Medicare|MEDICARE ACUTE|33.50||||33.50||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Tricare|TRICARE EAST REGION|33.50||||||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|33.50||||||| 9504408|ERX|0250|BUPIVACAINE 0.5%PF 30ML|Blue Cross PPO Specialty|BCBSTX PPO|33.50||||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|Humana Medicare Advantage|HUMANA MA|33.50||||||| 9504416|ERX|0250|BUPIVACAINE 0.75%PF 10ML|Blue Cross PPO Specialty|BCBSTX PPO|37.75||||||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||44.25||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Medicare|MEDICARE ACUTE|44.25||||44.25||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Tricare|TRICARE EAST REGION|44.25||||||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|United Medicare Advantage|UHC MEDICARE GOLD MA|44.25||||44.25||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Managed Medicaid|MEDICAID SUPERIOR|||||44.25||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Humana Medicare Advantage|HUMANA MA|44.25||||44.25||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|44.25||||44.25||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||44.25||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Blue Cross HMO Specialty|BCBSTX HMO|||||44.25||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||44.25||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Aetna|AETNA OTHER|||||44.25||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Aetna|AETNA PPO|||||44.25||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|United Healthcare|UNITED HEALTHCARE|||||44.25||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||44.25||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Blue Cross PPO Specialty|BCBSTX OTHER|||||44.25||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Blue Cross PPO Specialty|BCBSTX PPO|44.25||||44.25||| 9504473|ERX|0250|BUPIVACAINE 0.5% MDV 50ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||44.25||| 9504481|ERX|0250|DEXMEDETOMIDINE 200MCG/2M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.01||||||| 9504481|ERX|0250|DEXMEDETOMIDINE 200MCG/2M|Medicare|MEDICARE ACUTE|7.01||||||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|NON CONTRACTED|COMMERCIAL OTHER 1|||||83.75||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|Medicare|MEDICARE ACUTE|83.75||||83.75||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|Tricare|TRICARE EAST REGION|||||83.75||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|United Healthcare|UNITED HEALTHCARE|||||83.75||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|United Medicare Advantage|UHC MEDICARE GOLD MA|83.75||||||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|United Medicare Advantage|AARP UHC WEST COMPLETE MA|83.75||||83.75||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|Veterans Affairs|VETERANS ADMINISTRATION|83.75||||||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||83.75||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||83.75||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|Blue Cross HMO Specialty|BCBSTX HMO|||||83.75||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|Aenta Medicare Advantage|AETNA MEDICARE MA|83.75||||||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|Aetna|AETNA PPO|||||83.75||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||83.75||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|Blue Cross PPO Specialty|BCBSTX PPO|||||83.75||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|Humana Medicare Advantage|HUMANA MA|83.75||||||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|Brinson Benefits|THE HEALTH PLAN SMITH CO|83.75||||||| 9504507|ERX|0250|BUPIVACAINE-EPI 0.25%PF 3|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||83.75||| 9504515|ERX|0250|BUPIVACAINE-EPI 0.5%PF 10|Blue Cross PPO Specialty|BCBSTX PPO|||||37.50||| 9504515|ERX|0250|BUPIVACAINE-EPI 0.5%PF 10|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||37.50||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Tricare|TRICARE EAST REGION|||||64.75||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Medicare|MEDICARE ACUTE|64.75||||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|Managed Medicare|BCBS MEDICARE PPO MA|||||64.75||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Medicaid|MEDICAID|||||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|United Medicare Advantage|AARP UHC WEST COMPLETE MA|64.75||||||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|United Medicare Advantage|UHC MEDICARE GOLD MA|64.75||||64.75||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Veterans Affairs|VETERANS ADMINISTRATION|||||64.75||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Cigna|CIGNA|||||64.75||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|United Healthcare|UNITED HEALTHCARE OTHER|||||64.75||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Humana Medicare Advantage|HUMANA MA|64.75||||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 CIGNA HEALTHSPRING|||||64.75||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Managed Medicaid|MEDICAID SUPERIOR|||||64.75||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|NON CONTRACTED|COMMERCIAL OTHER 1|||||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|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|64.75||||64.75||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||64.75||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Aenta Medicare Advantage|AETNA MEDICARE MA|64.75||||64.75||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Blue Cross HMO Specialty|BCBSTX HMO|||||64.75||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Aetna|AETNA PPO|||||64.75||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|64.75||||64.75||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|64.75||||64.75||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Blue Cross PPO Specialty|BCBSTX PPO|||||64.75||| 9504523|ERX|0250|BUPIVACAINE-EPI 0.5%PF 30|Blue Cross PPO Specialty|BCBSTX OTHER|||||64.75||| 9504549|ERX|0250|MEASLES,MUMPS&RUBELLA VAC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|569.25||||||| 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|Medicaid|MEDICAID|569.25||||||| 9504564|ERX|0250|TETRACAINE 2% SOLUTION, 3|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||187.75||| 9504648|ERX|0250|LABETALOL 100MG/20ML|NON CONTRACTED|COMMERCIAL OTHER 2|||||4.48||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Medicare|MEDICARE ACUTE|4.48||||4.48||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Rusk State Hospital|RUSK STATE HOSP|4.48||||||| 9504648|ERX|0250|LABETALOL 100MG/20ML|United Healthcare|UNITED HEALTHCARE OTHER|||||4.48||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||4.48||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||4.48||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Managed Medicare|HEALTHSPRING MA|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 DUAL COMPLETE HMO SNP MA|4.48||||4.48||| 9504648|ERX|0250|LABETALOL 100MG/20ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||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|UTMB|UTMB CORRECTIONAL MANAGED CARE|4.48||||4.48||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Workers Compensation|UT EMPLOYEE INJURY|4.48||||||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Veterans Affairs|VETERANS ADMINISTRATION|4.48||||||| 9504648|ERX|0250|LABETALOL 100MG/20ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||4.48||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||4.48||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||4.48||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Managed Medicaid|MEDICAID AMERIGROUP|||||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 SUPERIOR|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|Blue Cross PPO Specialty|BCBSTX PPO|4.48||||4.48||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Blue Cross HMO Specialty|BCBSTX HMO|4.48||||4.48||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|4.48||||||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||4.48||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Aetna|AETNA PPO|||||4.48||| 9504648|ERX|0250|LABETALOL 100MG/20ML|Aenta Medicare Advantage|AETNA MEDICARE MA|4.48||||4.48||| 9504671|ERX|0258|DOBUTAMINE 250MG/250ML D5|Humana Medicare Advantage|HUMANA MA|1.79||||||| 9504671|ERX|0258|DOBUTAMINE 250MG/250ML D5|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.79||||1.79||| 9504671|ERX|0258|DOBUTAMINE 250MG/250ML D5|NON CONTRACTED|COMMERCIAL OTHER 1|1.79||||||| 9504671|ERX|0258|DOBUTAMINE 250MG/250ML D5|Medicare|MEDICARE ACUTE|1.79||||||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|NON CONTRACTED|COMMERCIAL OTHER 1|12.50||||12.50||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Medicare|MEDICARE PART B ONLY IP|||||12.50||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Medicare|MEDICARE ACUTE|12.50||||12.50||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|12.50||||||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|United Healthcare|UNITED HEALTHCARE OTHER|12.50||||||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|United Healthcare|UNITED HEALTHCARE|12.50||||12.50||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||12.50||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|12.50||||||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Medicaid|MEDICAID|12.50||||||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|United Medicare Advantage|UHC MEDICARE GOLD MA|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|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|12.50||||12.50||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12.50||||||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Blue Cross HMO Specialty|BCBSTX HMO|12.50||||12.50||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Blue Cross PPO Specialty|BCBSTX PPO|12.50||||12.50||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||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 UNITED HEALTHCARE|12.50||||12.50||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||12.50||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Managed Medicaid|MEDICAID AMERIGROUP|12.50||||||| 9504697|ERX|0250|EPHEDRINE 50MG/ML|Managed Medicaid|MEDICAID SUPERIOR|12.50||||12.50||| 9504739|ERX|0250|ACETYLCYSTEINE 20%, 30ML|Medicare|MEDICARE ACUTE|72.75||||||| 9504747|ERX|0250|SUFENTANIL 50MCG/1ML|Medicare|MEDICARE ACUTE|0.67||||||| 9504796|ERX|0250|RALOXIFENE 60MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|35.25||||||| 9504796|ERX|0250|RALOXIFENE 60MG TABLET|Medicare|MEDICARE ACUTE|35.25||||||| 9504804|ERX|0250|FONDAPARINUX 2.5MG/0.5ML|Medicare|MEDICARE ACUTE|429.75||||||| 9504804|ERX|0250|FONDAPARINUX 2.5MG/0.5ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|429.75||||||| 9504804|ERX|0250|FONDAPARINUX 2.5MG/0.5ML|Aenta Medicare Advantage|AETNA MEDICARE MA|429.75||||||| 9504846|ERX|0250|LIDOCAINE 1%PF 30ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||27.50||| 9504846|ERX|0250|LIDOCAINE 1%PF 30ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|27.50||||||| 9504846|ERX|0250|LIDOCAINE 1%PF 30ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||27.50||| 9504846|ERX|0250|LIDOCAINE 1%PF 30ML|Blue Cross PPO Specialty|BCBSTX PPO|27.50||||||| 9504846|ERX|0250|LIDOCAINE 1%PF 30ML|Humana Medicare Advantage|HUMANA MA|27.50||||||| 9504846|ERX|0250|LIDOCAINE 1%PF 30ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||27.50||| 9504846|ERX|0250|LIDOCAINE 1%PF 30ML|Medicare|MEDICARE ACUTE|27.50||||||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|Medicare|MEDICARE ACUTE|0.56||||||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|Humana Medicare Advantage|HUMANA MA|0.56||||||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|Managed Medicaid|MEDICAID SUPERIOR|0.56||||||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.56||||||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.56||||||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.56||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.56||||||| 9504879|ERX|0250|VANCOMYCIN 500MG VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|0.56||||||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||12.50||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|Blue Cross PPO Specialty|BCBSTX PPO|12.50||||||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|Managed Medicaid|MEDICAID AMERIGROUP|||||12.50||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||12.50||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|Managed Medicaid|MEDICAID SUPERIOR|||||12.50||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|Managed Medicare|HEALTHSPRING MA|12.50||||||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|Medicaid|MEDICAID|12.50||||12.50||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|Medicare|MEDICARE ACUTE|||||12.50||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|Rusk State Hospital|RUSK STATE HOSP|12.50||||12.50||| 9504929|ERX|0250|WATER FOR INJ.,STERILE 20|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||12.50||| 9504978|ERX|0250|NA BICARB 8.4% 10 MEQ/10M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||58.25||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Medicare|MEDICARE ACUTE|59.25||||59.25||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Rusk State Hospital|RUSK STATE HOSP|59.25||||||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|United Healthcare|UNITED HEALTHCARE|||||59.25||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|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|UHC MEDICARE GOLD MA|59.25||||59.25||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|United Medicare Advantage|AARP UHC WEST COMPLETE MA|59.25||||59.25||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Blue Cross HMO Specialty|BCBSTX HMO|||||59.25||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|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/|Aenta Medicare Advantage|AETNA MEDICARE MA|59.25||||59.25||| 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||||59.25||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Managed Medicaid|MEDICAID SUPERIOR|59.25||||||| 9504986|ERX|0250|D50%-WATER,ABBOJECT 25 G/|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||59.25||| 9504994|ERX|0250|LIDOCAINE ABBOJECT 100MG/|Medicare|MEDICARE ACUTE|||||44.75||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|Humana Medicare Advantage|HUMANA MA|46.25||||46.25||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||46.25||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||46.25||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|Blue Cross HMO Specialty|BCBSTX HMO|46.25||||||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|Blue Cross PPO Specialty|BCBSTX PPO|||||46.25||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|Aenta Medicare Advantage|AETNA MEDICARE MA|46.25||||46.25||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|United Medicare Advantage|AARP UHC WEST COMPLETE MA|46.25||||46.25||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|Workers Compensation|WORKERS COMPENSATION OTHER|||||46.25||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|Medicaid|MEDICAID|46.25||||46.25||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|United Healthcare|UNITED HEALTHCARE|46.25||||||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|Medicare|MEDICARE ACUTE|46.25||||46.25||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|Rusk State Hospital|RUSK STATE HOSP|46.25||||||| 9505009|ERX|0250|ATROPINE ABBOJECT 1MG/10M|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||46.25||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||144.50||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Medicare|MEDICARE ACUTE|144.50||||144.50||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Rusk State Hospital|RUSK STATE HOSP|144.50||||||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|United Healthcare|UNITED HEALTHCARE|144.50||||||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Medicaid|COUNTY INDIGENT HEALTH OTHER|144.50||||||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Medicaid|MEDICAID|144.50||||144.50||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|United Medicare Advantage|AARP UHC WEST COMPLETE MA|144.50||||144.50||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Workers Compensation|WORKERS COMPENSATION OTHER|||||144.50||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Blue Cross HMO Specialty|BCBSTX HMO|144.50||||144.50||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Blue Cross PPO Specialty|BCBSTX PPO|||||144.50||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Aenta Medicare Advantage|AETNA MEDICARE MA|144.50||||||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Humana Medicare Advantage|HUMANA MA|144.50||||144.50||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||144.50||| 9505017|ERX|0250|EPINEPHRINE ABBOJECT 1MG/|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||144.50||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|Humana Medicare Advantage|HUMANA MA|47.25||||||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||47.25||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|Blue Cross HMO Specialty|BCBSTX HMO|47.25||||||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|Blue Cross PPO Specialty|BCBSTX PPO|||||47.25||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|47.25||||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||| 9505025|ERX|0250|CA CHLORIDE 1000MG/10ML|Rusk State Hospital|RUSK STATE HOSP|47.25||||||| 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|NON CONTRACTED|COMMERCIAL OTHER 1|12.50||||||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Medicare|MEDICARE ACUTE|12.50||||12.50||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|12.50||||||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|United Medicare Advantage|AARP UHC WEST COMPLETE 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|UHC DUAL COMPLETE HMO SNP MA|||||12.50||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Veterans Affairs|VETERANS ADMINISTRATION|||||12.50||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Blue Cross PPO Specialty|BCBSTX OTHER|12.50||||||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12.50||||||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Blue Cross PPO Specialty|BCBSTX PPO|12.50||||12.50||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Aenta Medicare Advantage|AETNA MEDICARE MA|12.50||||||| 9505090|ERX|0250|FUROSEMIDE 20MG/2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|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|Humana Medicare Advantage|HUMANA MA|12.50||||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 UNITED HEALTHCARE|12.50||||12.50||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Managed Medicaid|MEDICAID SUPERIOR|12.50||||||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Blue Cross HMO Specialty|BCBSTX HMO|||||12.50||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||12.50||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Aetna|AETNA PPO|||||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 PPO Specialty|BCBSTX OTHER|12.50||||||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Aenta Medicare Advantage|AETNA MEDICARE MA|12.50||||||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Managed Medicaid|MEDICAID AMERIGROUP|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 SOLUTIONS MA|||||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|United Medicare Advantage|UHC MEDICARE GOLD MA|12.50||||12.50||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Veterans Affairs|VETERANS ADMINISTRATION|||||12.50||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|NON CONTRACTED|COMMERCIAL OTHER 1|12.50||||12.50||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Medicare|MEDICARE PART B ONLY IP|12.50||||||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Medicare|MEDICARE ACUTE|12.50||||12.50||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Tricare|TRICARE EAST REGION|||||12.50||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|12.50||||||| 9505108|ERX|0250|FUROSEMIDE 40MG/4ML|Managed Medicare|HEALTHSPRING MA|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|12.50||||12.50||| 9505116|ERX|0250|FUROSEMIDE 100MG/10ML|NON CONTRACTED|COMMERCIAL OTHER 1|12.50||||||| 9505116|ERX|0250|FUROSEMIDE 100MG/10ML|Medicare|MEDICARE ACUTE|12.50||||||| 9505116|ERX|0250|FUROSEMIDE 100MG/10ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|12.50||||||| 9505116|ERX|0250|FUROSEMIDE 100MG/10ML|Blue Cross PPO Specialty|BCBSTX OTHER|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||||||| 9505124|ERX|0258|NA CHLORIDE 0.9%,500ML IR|Humana Medicare Advantage|HUMANA MA|136.75||||||| 9505124|ERX|0258|NA CHLORIDE 0.9%,500ML IR|Blue Cross PPO Specialty|BCBSTX PPO|136.75||||||| 9505124|ERX|0258|NA CHLORIDE 0.9%,500ML IR|Managed Medicaid|MEDICAID SUPERIOR|136.75||||||| 9505124|ERX|0258|NA CHLORIDE 0.9%,500ML IR|Managed Medicaid|MEDICAID AMERIGROUP|136.75||||||| 9505124|ERX|0258|NA CHLORIDE 0.9%,500ML IR|Medicare|MEDICARE ACUTE|136.75||||136.75||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|NON CONTRACTED|COMMERCIAL OTHER 1|109.75||||||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Medicare|MEDICARE ACUTE|109.75||||109.75||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|109.75||||||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Managed Medicare|HEALTHSPRING MA|109.75||||||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||109.75||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|109.75||||||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Workers Compensation|WORKERS COMPENSATION OTHER|||||109.75||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Blue Cross HMO Specialty|BCBSTX HMO|109.75||||109.75||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Aetna|AETNA PPO|109.75||||||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|109.75||||||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Blue Cross PPO Specialty|BCBSTX OTHER|||||109.75||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|109.75||||||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Brinson Benefits|THE HEALTH PLAN SMITH CO|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 CIGNA HEALTHSPRING|109.75||||||| 9505173|ERX|0250|VANCOMYCIN 1000MG VIAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|109.75||||||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Cigna|CIGNA|||||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 AMERIGROUP|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,|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|35.25||||35.25||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||35.25||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||35.25||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Blue Cross HMO Specialty|BCBSTX HMO|35.25||||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,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|35.25||||35.25||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Aenta Medicare Advantage|AETNA MEDICARE 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,|United Medicare Advantage|UHC MEDICARE GOLD MA|35.25||||35.25||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|35.25||||35.25||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Workers Compensation|WORKERS COMPENSATION OTHER|||||35.25||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Managed Medicare|BCBS MEDICARE PPO MA|||||35.25||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||35.25||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Managed Medicare|HEALTHSPRING MA|35.25||||||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Humana Medicare Advantage|HUMANA MA|35.25||||35.25||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Medicaid|MEDICAID|35.25||||35.25||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||35.25||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|NON CONTRACTED|COMMERCIAL OTHER 1|35.25||||35.25||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Medicare|MEDICARE ACUTE|35.25||||35.25||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|Rusk State Hospital|RUSK STATE HOSP|35.25||||35.25||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|United Healthcare|UNITED HEALTHCARE|||||35.25||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|United Healthcare|UNITED HEALTHCARE OTHER|35.25||||35.25||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|UTMB|UTMB CORRECTIONAL MANAGED CARE|35.25||||35.25||| 9505207|ERX|0250|SUCCINYLCHOLINE 20MG/ML,|United Healthcare|UNITED HEALTHCARE|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|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||0.41||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Rusk State Hospital|RUSK STATE HOSP|0.41||||||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|United Healthcare|UNITED HEALTHCARE|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|Medicaid|MEDICAID|0.41||||||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.41||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.41||||0.41||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.41||||0.41||| 9505215|ERX|0250|NA BICARB 8.4% 50 MEQ/50M|Blue Cross HMO Specialty|BCBSTX HMO|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|Aenta Medicare Advantage|AETNA MEDICARE MA|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 CIGNA HEALTHSPRING|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|Managed Medicaid|MEDICAID SUPERIOR|12.50||||||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||12.50||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|Managed Medicaid|MEDICAID AMERIGROUP|12.50||||||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP 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||||||| 9505223|ERX|0250|K CHLORIDE 2 MEQ/ML,20ML|United Healthcare|UNITED HEALTHCARE OTHER|12.50||||||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Medicare|MEDICARE ACUTE|24.50||||24.50||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|24.50||||||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|24.50||||||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|24.50||||24.50||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|24.50||||24.50||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|||||24.50||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|24.50||||||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|24.50||||||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|24.50||||||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Humana Medicare Advantage|HUMANA MA|24.50||||24.50||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||24.50||| 9505231|ERX|0250|CARVEDILOL 3.125MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|24.50||||||| 9505256|ERX|0258|MAGNESIUM SULF 4 G/100ML|Humana Medicare Advantage|HUMANA MA|187.75||||||| 9505256|ERX|0258|MAGNESIUM SULF 4 G/100ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|187.75||||||| 9505256|ERX|0258|MAGNESIUM SULF 4 G/100ML|Aenta Medicare Advantage|AETNA MEDICARE MA|187.75||||||| 9505256|ERX|0258|MAGNESIUM SULF 4 G/100ML|Blue Cross PPO Specialty|BCBSTX PPO|187.75||||187.75||| 9505256|ERX|0258|MAGNESIUM SULF 4 G/100ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|187.75||||||| 9505256|ERX|0258|MAGNESIUM SULF 4 G/100ML|United Medicare Advantage|UHC MEDICARE GOLD MA|187.75||||||| 9505256|ERX|0258|MAGNESIUM SULF 4 G/100ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|187.75||||||| 9505256|ERX|0258|MAGNESIUM SULF 4 G/100ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|187.75||||||| 9505256|ERX|0258|MAGNESIUM SULF 4 G/100ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|187.75||||||| 9505256|ERX|0258|MAGNESIUM SULF 4 G/100ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|187.75||||||| 9505256|ERX|0258|MAGNESIUM SULF 4 G/100ML|Managed Medicaid|MEDICAID AMERIGROUP|187.75||||||| 9505256|ERX|0258|MAGNESIUM SULF 4 G/100ML|Medicaid|MEDICAID|187.75||||||| 9505256|ERX|0258|MAGNESIUM SULF 4 G/100ML|NON CONTRACTED|COMMERCIAL OTHER 1|187.75||||||| 9505256|ERX|0258|MAGNESIUM SULF 4 G/100ML|Medicare|MEDICARE ACUTE|187.75||||187.75||| 9505256|ERX|0258|MAGNESIUM SULF 4 G/100ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|187.75||||||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|NON CONTRACTED|COMMERCIAL OTHER 1|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|Medicaid|MEDICAID|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 Medicaid|MEDICAID UNITED HEALTHCARE|||||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 CIGNA HEALTHSPRING|114.50||||||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|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|United Medicare Advantage|UHC MEDICARE GOLD MA|114.50||||||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|114.50||||||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||114.50||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Blue Cross PPO Specialty|BCBSTX OTHER|114.50||||||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Aenta Medicare Advantage|AETNA MEDICARE MA|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 PPO Specialty|BCBSTX PPO|114.50||||114.50||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Humana Medicare Advantage|HUMANA MA|114.50||||||| 9505264|ERX|0258|MAGNESIUM SULF 2 GM/50ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|114.50||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Humana Medicare Advantage|HUMANA MA|199.75||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|199.75||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Cigna|CIGNA|199.75||||199.75||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Cigna|CIGNA|||||199.75||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|199.75||||199.75||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|199.75||||199.75||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Aenta Medicare Advantage|AETNA MEDICARE MA|199.75||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Blue Cross HMO Specialty|BCBSTX HMO|||||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|Workers Compensation|WORKERS COMPENSATION OTHER|199.75||||199.75||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|United Medicare Advantage|UHC MEDICARE GOLD MA|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|Managed Medicare|HEALTHSPRING MA|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 SUPERIOR|||||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|Medicaid|MEDICAID|199.75||||||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|Medicare|MEDICARE PART B ONLY IP|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|Rusk State Hospital|RUSK STATE HOSP|||||199.75||| 9505272|ERX|0258|K CHLORIDE 20 MEQ/100ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|199.75||||199.75||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|UTMB|UTMB CORRECTIONAL MANAGED CARE|206.75||||||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|Rusk State Hospital|RUSK STATE HOSP|206.75||||||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|Managed Medicaid|MEDICAID SUPERIOR|206.75||||||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|Managed Medicaid|MEDICAID AMERIGROUP|206.75||||206.75||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|Medicaid|MOLINA HEALTHCARE OF TEXAS|206.75||||||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|206.75||||206.75||| 9505314|ERX|0258|DEX 5%-NS KCL 20 MEQ 1000|Blue Cross PPO Specialty|BCBSTX PPO|206.75||||||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|24.50||||||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|24.50||||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 SOLUTIONS MA|||||24.50||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|24.50||||||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Cigna|CIGNA|24.50||||||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Humana Medicare Advantage|HUMANA MA|24.50||||24.50||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|24.50||||||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|24.50||||||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|24.50||||||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|24.50||||||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|24.50||||24.50||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Medicaid|MEDICAID|||||24.50||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|24.50||||24.50||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Medicare|MEDICARE ACUTE|24.50||||24.50||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|Rusk State Hospital|RUSK STATE HOSP|24.50||||||| 9505389|ERX|0250|CARVEDILOL 12.5MG TABLET|United Healthcare|UNITED HEALTHCARE|24.50||||||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||18.25||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|United Healthcare|UNITED HEALTHCARE OTHER|||||18.25||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Medicare|MEDICARE ACUTE|18.25||||18.25||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Managed Medicare|HEALTHSPRING MA|||||18.25||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Medicaid|MEDICAID|||||18.25||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Aenta Medicare Advantage|AETNA MEDICARE MA|18.25||||||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||18.25||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||18.25||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||18.25||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Blue Cross HMO Specialty|BCBSTX HMO|||||18.25||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||18.25||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Aetna|AETNA PPO|||||18.25||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Blue Cross PPO Specialty|BCBSTX PPO|||||18.25||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Managed Medicaid|MEDICAID SUPERIOR|||||18.25||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||18.25||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Managed Medicaid|MEDICAID AMERIGROUP|||||18.25||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||18.25||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Humana Medicare Advantage|HUMANA MA|18.25||||18.25||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||18.25||| 9505413|ERX|0250|EPINEPHRINE 1MG/ML|Workers Compensation|WORKERS COMPENSATION OTHER|||||18.25||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|12.50||||||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|United Medicare Advantage|AARP UHC WEST COMPLETE MA|12.50||||||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|Workers Compensation|UT EMPLOYEE INJURY|12.50||||||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|Veterans Affairs|VETERANS ADMINISTRATION|12.50||||||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|Humana Medicare Advantage|HUMANA MA|12.50||||||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|12.50||||||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|12.50||||||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|Aenta Medicare Advantage|AETNA MEDICARE MA|12.50||||||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12.50||||||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|Blue Cross HMO Specialty|BCBSTX HMO|12.50||||||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|Managed Medicare|HEALTHSPRING MA|12.50||||||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|Medicaid|MEDICAID|12.50||||||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|Medicaid|COUNTY INDIGENT HEALTH OTHER|12.50||||||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|NON CONTRACTED|COMMERCIAL OTHER 1|12.50||||||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|Medicare|MEDICARE ACUTE|12.50||||||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|Medicare|MEDICARE PART B ONLY IP|12.50||||||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|Rusk State Hospital|RUSK STATE HOSP|12.50||||||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|UTMB|UTMB CORRECTIONAL MANAGED CARE|12.50||||||| 9505439|ERX|0250|K PHOSPHATE 3 MMOL/ML,15M|United Healthcare|TML GROUP BENEFITS|12.50||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Medicare|MEDICARE ACUTE|12.50||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Rusk State Hospital|RUSK STATE HOSP|12.50||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|United Healthcare|UNITED HEALTHCARE|12.50||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|UTMB|UTMB CORRECTIONAL MANAGED CARE|12.50||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|12.50||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Managed Medicare|HEALTHSPRING MA|12.50||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Medicaid|COUNTY INDIGENT HEALTH OTHER|12.50||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|NON CONTRACTED|COMMERCIAL OTHER 1|12.50||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Medicaid|MEDICAID|12.50||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Aenta Medicare Advantage|AETNA MEDICARE MA|12.50||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Blue Cross HMO Specialty|BCBSTX HMO|12.50||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12.50||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Humana Medicare Advantage|HUMANA MA|12.50||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||12.50||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|12.50||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|12.50||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|12.50||||||| 9505447|ERX|0250|NA PHOSPHATE 3 MMOL/ML,15|United Medicare Advantage|AARP UHC WEST COMPLETE MA|12.50||||||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|United Medicare Advantage|AARP UHC WEST COMPLETE MA|162.50||||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|Veterans Affairs|VETERANS ADMINISTRATION|||||162.50||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|Cigna|CIGNA|162.50||||||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|Humana Medicare Advantage|HUMANA MA|162.50||||162.50||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|Aenta Medicare Advantage|AETNA MEDICARE MA|162.50||||||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|162.50||||||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|Blue Cross HMO Specialty|BCBSTX HMO|||||162.50||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|162.50||||||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|Medicaid|MEDICAID|||||162.50||| 9505553|ERX|0250|HEPARIN 25,000 UNITS/500M|UTMB|UTMB CORRECTIONAL MANAGED CARE|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|United Healthcare|UNITED HEALTHCARE|||||162.50||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|NON CONTRACTED|COMMERCIAL OTHER 1|103.25||||||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|United Healthcare|UNITED HEALTHCARE|||||103.25||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Medicare|MEDICARE ACUTE|103.25||||103.25||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Managed Medicare|HEALTHSPRING MA|103.25||||||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|103.25||||||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Medicaid|MEDICAID|103.25||||||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||103.25||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Aenta Medicare Advantage|AETNA MEDICARE MA|103.25||||103.25||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Blue Cross HMO Specialty|BCBSTX HMO|||||103.25||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Blue Cross PPO Specialty|BCBSTX PPO|||||103.25||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Managed Medicaid|MEDICAID SUPERIOR|103.25||||||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Humana Medicare Advantage|HUMANA MA|103.25||||103.25||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Managed Medicaid|MEDICAID AMERIGROUP|103.25||||||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|103.25||||||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||103.25||| 9505579|ERX|0250|METRONIDAZOLE 500MG/100ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|103.25||||103.25||| 9505611|ERX|0258|DEX 5%-1/4NS KCL 20 MEQ 1|United Medicare Advantage|UHC MEDICARE GOLD MA|1.79||||||| 9505611|ERX|0258|DEX 5%-1/4NS KCL 20 MEQ 1|Humana Medicare Advantage|HUMANA MA|1.79||||||| 9505611|ERX|0258|DEX 5%-1/4NS KCL 20 MEQ 1|Medicaid|MEDICAID HMO|||||1.79||| 9505611|ERX|0258|DEX 5%-1/4NS KCL 20 MEQ 1|Managed Medicaid|MEDICAID SUPERIOR|1.79||||1.79||| 9505611|ERX|0258|DEX 5%-1/4NS KCL 20 MEQ 1|Medicaid|MEDICAID|1.79||||||| 9505611|ERX|0258|DEX 5%-1/4NS KCL 20 MEQ 1|Medicaid|SUPERIOR HEALTHPLAN CHIP|1.79||||||| 9505611|ERX|0258|DEX 5%-1/4NS KCL 20 MEQ 1|Medicare|MEDICARE ACUTE|1.79||||||| 9505660|ERX|0258|DEXTROSE 5% KCL 20 MEQ 10|Medicare|MEDICARE ACUTE|1.79||||||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Blue Cross PPO Specialty|BCBSTX PPO|195.75||||||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Humana Medicare Advantage|HUMANA MA|195.75||||||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|United Medicare Advantage|UHC MEDICARE GOLD MA|195.75||||||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|195.75||||195.75||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||195.75||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||195.75||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|Medicare|MEDICARE ACUTE|195.75||||||| 9505728|ERX|0258|DEXTROSE 5%-WATER 50ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|195.75||||||| 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 SUPERIOR|174.75||||174.75||| 9505751|ERX|0258|DEXTROSE 5%-1/4 NS 1000ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|174.75||||||| 9505751|ERX|0258|DEXTROSE 5%-1/4 NS 1000ML|Managed Medicaid|MEDICAID AMERIGROUP|174.75||||174.75||| 9505751|ERX|0258|DEXTROSE 5%-1/4 NS 1000ML|Medicaid|MEDICAID|174.75||||174.75||| 9505751|ERX|0258|DEXTROSE 5%-1/4 NS 1000ML|United Medicare Advantage|UHC MEDICARE GOLD MA|174.75||||||| 9505751|ERX|0258|DEXTROSE 5%-1/4 NS 1000ML|Humana Medicare Advantage|HUMANA MA|174.75||||||| 9505751|ERX|0258|DEXTROSE 5%-1/4 NS 1000ML|Blue Cross PPO Specialty|BCBSTX PPO|174.75||||||| 9505785|ERX|0258|DEXTROSE 10%-WATER 500ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|132.75||||||| 9505785|ERX|0258|DEXTROSE 10%-WATER 500ML|Managed Medicaid|MEDICAID SUPERIOR|132.75||||||| 9505785|ERX|0258|DEXTROSE 10%-WATER 500ML|Managed Medicaid|MEDICAID AMERIGROUP|132.75||||||| 9505785|ERX|0258|DEXTROSE 10%-WATER 500ML|Medicaid|MEDICAID|132.75||||||| 9505785|ERX|0258|DEXTROSE 10%-WATER 500ML|Medicare|MEDICARE ACUTE|132.75||||||| 9505793|ERX|0258|DEXTROSE 10%-WATER 1000ML|Medicare|MEDICARE ACUTE|198.50||||||| 9505793|ERX|0258|DEXTROSE 10%-WATER 1000ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||198.50||| 9505793|ERX|0258|DEXTROSE 10%-WATER 1000ML|Managed Medicaid|MEDICAID SUPERIOR|198.50||||||| 9505793|ERX|0258|DEXTROSE 10%-WATER 1000ML|Managed Medicaid|MEDICAID AMERIGROUP|198.50||||||| 9505793|ERX|0258|DEXTROSE 10%-WATER 1000ML|Medicaid|MEDICAID|198.50||||||| 9505918|ERX|0258|SODIUM CHLORIDE 0.9% 150M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.13||||||| 9505918|ERX|0258|SODIUM CHLORIDE 0.9% 150M|Managed Medicaid|MEDICAID AMERIGROUP|1.13||||||| 9505934|ERX|0250|ROPINIROLE 1MG TABLET|Medicare|MEDICARE ACUTE|27.50||||27.50||| 9505934|ERX|0250|ROPINIROLE 1MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|27.50||||||| 9505934|ERX|0250|ROPINIROLE 1MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|27.50||||||| 9505934|ERX|0250|ROPINIROLE 1MG TABLET|Humana Medicare Advantage|HUMANA MA|27.50||||27.50||| 9505934|ERX|0250|ROPINIROLE 1MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|27.50||||||| 9505934|ERX|0250|ROPINIROLE 1MG TABLET|Aetna|AETNA OTHER|27.50||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Aenta Medicare Advantage|AETNA MEDICARE MA|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|Humana Medicare Advantage|HUMANA MA|209.50||||209.50||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Brinson Benefits|THE HEALTH PLAN SMITH CO|209.50||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Veterans Affairs|VETERANS ADMINISTRATION|209.50||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|209.50||||209.50||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|United Medicare Advantage|AARP UHC WEST COMPLETE MA|209.50||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|209.50||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Managed Medicare|HEALTHSPRING MA|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|Managed Medicaid|MEDICAID SUPERIOR|209.50||||209.50||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Medicaid|MEDICAID|209.50||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|NON CONTRACTED|COMMERCIAL OTHER 1|209.50||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Medicare|MEDICARE PART B ONLY IP|209.50||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Medicare|MEDICARE ACUTE|209.50||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|Rusk State Hospital|RUSK STATE HOSP|209.50||||||| 9505959|ERX|0258|SODIUM CHLORIDE 0.45% 100|UTMB|UTMB CORRECTIONAL MANAGED CARE|209.50||||||| 9505967|ERX|0258|WATER FOR INJECTION 1000M|Managed Medicaid|MEDICAID SUPERIOR|140.75||||||| 9505967|ERX|0258|WATER FOR INJECTION 1000M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|140.75||||||| 9505967|ERX|0258|WATER FOR INJECTION 1000M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||140.75||| 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|Humana Medicare Advantage|HUMANA MA|163.50||||||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Managed Medicaid|MEDICAID SUPERIOR|163.50||||||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|163.50||||163.50||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Blue Cross HMO Specialty|BCBSTX HMO|||||163.50||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Medicare|MEDICARE ACUTE|163.50||||163.50||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Rusk State Hospital|RUSK STATE HOSP|163.50||||163.50||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|163.50||||163.50||| 9505983|ERX|0250|ETOMIDATE 2MG/ML, 10ML|Medicaid|MEDICAID|||||163.50||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|Medicaid|MOLINA HEALTHCARE OF TEXAS|60.75||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|Medicaid|SUPERIOR HEALTHPLAN CHIP|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|MEDICAID|60.75||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|United Healthcare|UNITED HEALTHCARE OTHER|60.75||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|United Healthcare|UNITED HEALTHCARE|60.75||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|Blue Cross HMO Specialty|BCBSTX HMO|60.75||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|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|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|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|Cigna|CIGNA|60.75||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|60.75||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|Managed Medicaid|MEDICAID SUPERIOR|60.75||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|Managed Medicaid|MEDICAID AMERIGROUP|60.75||||||| 9506007|ERX|0250|PHYTONADIONE (PF) 1MG/0.5|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|60.75||||||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|118.75||||||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|118.75||||||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|Humana Medicare Advantage|HUMANA MA|118.75||||118.75||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|||||118.75||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|118.75||||118.75||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|118.75||||||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|Medicare|MEDICARE ACUTE|118.75||||118.75||| 9506015|ERX|0250|PHYTONADIONE 10MG/1ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||118.75||| 9506056|ERX|0258|FAT EMULSION 20% 500ML|Managed Medicare|HEALTHSPRING MA|110.04||||||| 9506056|ERX|0258|FAT EMULSION 20% 500ML|Medicare|MEDICARE ACUTE|110.04||||||| 9506056|ERX|0258|FAT EMULSION 20% 500ML|Humana Medicare Advantage|HUMANA MA|110.04||||||| 9506056|ERX|0258|FAT EMULSION 20% 500ML|Veterans Affairs|VETERANS ADMINISTRATION|110.04||||||| 9506064|ERX|0250|ESTRADIOL 1MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|21.50||||||| 9506064|ERX|0250|ESTRADIOL 1MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|21.50||||||| 9506064|ERX|0250|ESTRADIOL 1MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|21.50||||||| 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||||||| 9506064|ERX|0250|ESTRADIOL 1MG TABLET|Medicare|MEDICARE ACUTE|21.50||||||| 9506064|ERX|0250|ESTRADIOL 1MG TABLET|Rusk State Hospital|RUSK STATE HOSP|21.50||||||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|Medicaid|MEDICAID|||||0.15||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.15||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|Medicare|MEDICARE ACUTE|0.15||||0.15||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|United Healthcare|UMR UNITED MEDICAL RESOURCES|0.15||||||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|Managed Medicaid|MEDICAID SUPERIOR|||||0.15||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|Humana Medicare Advantage|HUMANA MA|||||0.15||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.15||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.15||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|Blue Cross HMO Specialty|BCBSTX HMO|||||0.15||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|Blue Cross PPO Specialty|BCBSTX PPO|||||0.15||| 9506072|ERX|0250|PHENAZOPYRIDINE 100MG TAB|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.15||| 9506106|ERX|0250|ESTRADIOL 0.01% VAG CRM,4|Medicare|MEDICARE ACUTE|991.50||||||| 9506114|ERX|0250|NA HYPOCHLOR 0.25% SOLN,4|Brinson Benefits|THE HEALTH PLAN SMITH CO|86.75||||||| 9506114|ERX|0250|NA HYPOCHLOR 0.25% SOLN,4|Medicaid|MEDICAID|86.75||||||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|NON CONTRACTED|COMMERCIAL OTHER 1|44.25||||||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|Medicare|MEDICARE ACUTE|44.25||||44.25||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|Managed Medicare|HEALTHSPRING MA|44.25||||||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|Humana Medicare Advantage|HUMANA MA|44.25||||||| 9506148|ERX|0250|VENLAFAXINE XL 75MG CAPSU|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|44.25||||||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|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|Workers Compensation|UT EMPLOYEE INJURY|0.16||||||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Workers Compensation|WORKERS COMPENSATION OTHER|0.16||||||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||0.16||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|0.16||||||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Aetna|AETNA PPO|||||0.16||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|0.16||||||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||0.16||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Humana Medicare Advantage|HUMANA MA|0.16||||0.16||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.16||||||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.16||||||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.16||||0.16||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|0.16||||||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Medicare|MEDICARE ACUTE|0.16||||0.16||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.16||||0.16||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|Rusk State Hospital|RUSK STATE HOSP|0.16||||||| 9506239|ERX|0250|BENZONATATE 100MG CAPSULE|United Healthcare|UNITED HEALTHCARE|0.16||||0.16||| 9506254|ERX|0250|LEVOTHYROXINE 88MCG TABLE|Medicare|MEDICARE ACUTE|0.05||||0.05||| 9506254|ERX|0250|LEVOTHYROXINE 88MCG TABLE|Humana Medicare Advantage|HUMANA MA|0.05||||||| 9506254|ERX|0250|LEVOTHYROXINE 88MCG TABLE|Aenta Medicare Advantage|AETNA MEDICARE MA|0.05||||||| 9506254|ERX|0250|LEVOTHYROXINE 88MCG TABLE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.05||||||| 9506254|ERX|0250|LEVOTHYROXINE 88MCG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|||||0.05||| 9506254|ERX|0250|LEVOTHYROXINE 88MCG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|0.05||||||| 9506270|ERX|0250|VENLAFAXINE XL 37.5MG CAP|Medicare|MEDICARE ACUTE|39.25||||||| 9506296|ERX|0250|NEBIVOLOL 5MG TABLET|Humana Medicare Advantage|HUMANA MA|||||16.50||| 9506296|ERX|0250|NEBIVOLOL 5MG TABLET|Medicare|MEDICARE ACUTE|16.50||||16.50||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|32.25||||||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|32.25||||||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Medicare|MEDICARE ACUTE|32.25||||32.25||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Rusk State Hospital|RUSK STATE HOSP|32.25||||||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|United Healthcare|UMR UNITED MEDICAL RESOURCES|32.25||||||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|32.25||||||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|32.25||||||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|32.25||||||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||32.25||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|32.25||||||| 9506320|ERX|0250|ESCITALOPRAM 10MG TABLET|Humana Medicare Advantage|HUMANA MA|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||||||| 9506353|ERX|0250|MEMANTINE 10MG TABLET|Humana Medicare Advantage|HUMANA MA|28.50||||28.50||| 9506353|ERX|0250|MEMANTINE 10MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|28.50||||||| 9506353|ERX|0250|MEMANTINE 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|28.50||||||| 9506353|ERX|0250|MEMANTINE 10MG TABLET|Medicare|MEDICARE ACUTE|28.50||||28.50||| 9506361|ERX|0250|OLANZAPINE 5MG ODT TABLET|Medicare|MEDICARE ACUTE|97.50||||||| 9506361|ERX|0250|OLANZAPINE 5MG ODT TABLET|Rusk State Hospital|RUSK STATE HOSP|97.50||||||| 9506361|ERX|0250|OLANZAPINE 5MG ODT TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|97.50||||||| 9506361|ERX|0250|OLANZAPINE 5MG ODT TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|97.50||||||| 9506361|ERX|0250|OLANZAPINE 5MG ODT TABLET|Humana Medicare Advantage|HUMANA MA|97.50||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.45||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Cigna|CIGNA|0.45||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|0.45||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|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|Humana Medicare Advantage|HUMANA MA|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|Aenta Medicare Advantage|AETNA MEDICARE MA|0.45||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.45||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.45||||0.45||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Aetna|AETNA PPO|0.45||||0.45||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|0.45||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.45||||0.45||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||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|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|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|AARP UHC WEST COMPLETE MA|0.45||||0.45||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.45||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|0.45||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.45||||0.45||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Workers Compensation|UT EMPLOYEE INJURY|0.45||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.45||||0.45||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Managed Medicare|HEALTHSPRING MA|0.45||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|0.45||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Medicaid|MEDICAID|0.45||||0.45||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.45||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 2|||||0.45||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.45||||0.45||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.45||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|United Healthcare|UMR UNITED MEDICAL RESOURCES|0.45||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Rusk State Hospital|RUSK STATE HOSP|0.45||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|Medicare|MEDICARE ACUTE|0.45||||0.45||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.45||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|0.45||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|United Healthcare|TML GROUP BENEFITS|0.45||||||| 9506379|ERX|0250|PANTOPRAZOLE 40MG TABLET|United Healthcare|UNITED HEALTHCARE|0.45||||||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|NON CONTRACTED|COMMERCIAL OTHER 1|||||1.63||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Rusk State Hospital|RUSK STATE HOSP|1.63||||||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.63||||1.63||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Tricare|TRICARE EAST REGION|||||1.63||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|United Healthcare|UNITED HEALTHCARE|1.63||||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||||1.63||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Managed Medicare|HEALTHSPRING MA|1.63||||1.63||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1.63||||1.63||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Medicaid|MEDICAID|1.63||||1.63||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||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|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||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|United Medicare Advantage|UHC MEDICARE GOLD MA|1.63||||1.63||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Veterans Affairs|VETERANS ADMINISTRATION|1.63||||1.63||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|1.63||||1.63||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||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|Medicare|MEDICARE ACUTE|1.63||||1.63||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Aetna|AETNA OTHER|||||1.63||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Aetna|AETNA PPO|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 PPO Specialty|BCBSTX OTHER|||||1.63||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Blue Cross HMO Specialty|BCBSTX HMO|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|Managed Medicaid|MEDICAID AMERIGROUP|1.63||||1.63||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Cigna|CIGNA|1.63||||||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Cigna|CIGNA|||||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 CIGNA HEALTHSPRING|1.63||||1.63||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Managed Medicaid|MEDICAID SUPERIOR|1.63||||1.63||| 9506452|ERX|0250|PANTOPRAZOLE 40MG VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.63||||1.63||| 9506569|ERX|0250|SULFA-TRIME 200-40MG/5ML,|Managed Medicaid|MEDICAID AMERIGROUP|||||36.50||| 9506569|ERX|0250|SULFA-TRIME 200-40MG/5ML,|Managed Medicaid|MEDICAID SUPERIOR|||||36.50||| 9506569|ERX|0250|SULFA-TRIME 200-40MG/5ML,|Blue Cross PPO Specialty|BCBSTX PPO|||||36.50||| 9506569|ERX|0250|SULFA-TRIME 200-40MG/5ML,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|36.50||||||| 9506569|ERX|0250|SULFA-TRIME 200-40MG/5ML,|Medicaid|MEDICAID|||||36.50||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|NON CONTRACTED|COMMERCIAL OTHER 1|167.50||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|Rusk State Hospital|RUSK STATE HOSP|167.50||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|Medicare|MEDICARE ACUTE|167.50||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|167.50||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|Blue Cross HMO Specialty|BCBSTX HMO|167.50||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|Aetna|AETNA OTHER|167.50||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|Blue Cross PPO Specialty|BCBSTX PPO|167.50||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|Humana Medicare Advantage|HUMANA MA|167.50||||||| 9506577|ERX|0250|NYSTATIN 100000 UNIT, 1ML|Managed Medicaid|MEDICAID AMERIGROUP|167.50||||||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Humana Medicare Advantage|HUMANA MA|29.75||||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 SUPERIOR|||||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|Blue Cross HMO Specialty|BCBSTX HMO|29.75||||29.75||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Aetna|AETNA OTHER|||||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|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||||29.75||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Managed Medicare|HOSPICE OF EAST TEXAS|29.75||||||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Medicaid|MEDICAID|29.75||||29.75||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Rusk State Hospital|RUSK STATE HOSP|29.75||||||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|29.75||||29.75||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|Medicare|MEDICARE ACUTE|29.75||||29.75||| 9506635|ERX|0250|LACTULOSE 10 G/15ML, 30ML|United Healthcare|UNITED HEALTHCARE|||||29.75||| 9506676|ERX|0250|POTASS-SOD PHOS 155-852-1|Medicare|MEDICARE ACUTE|4.75||||||| 9506684|ERX|0250|RACEPINEPHRINE 2.25% NEB|Blue Cross PPO Specialty|BCBSTX PPO|||||24.50||| 9506684|ERX|0250|RACEPINEPHRINE 2.25% NEB|Managed Medicaid|MEDICAID SUPERIOR|||||24.50||| 9506684|ERX|0250|RACEPINEPHRINE 2.25% NEB|Managed Medicaid|MEDICAID AMERIGROUP|24.50||||24.50||| 9506684|ERX|0250|RACEPINEPHRINE 2.25% NEB|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||24.50||| 9506684|ERX|0250|RACEPINEPHRINE 2.25% NEB|Medicaid|MEDICAID|||||24.50||| 9506692|ERX|0250|IPRATROPIUM 0.02% INH 2.5|Medicare|MEDICARE ACUTE|0.16||||0.16||| 9506692|ERX|0250|IPRATROPIUM 0.02% INH 2.5|Medicaid|MEDICAID|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|Veterans Affairs|VETERANS ADMINISTRATION|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|Managed Medicaid|MEDICAID SUPERIOR|0.16||||||| 9506692|ERX|0250|IPRATROPIUM 0.02% INH 2.5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.16||||0.16||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.08||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Blue Cross HMO Specialty|BCBSTX HMO|0.08||||||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Blue Cross PPO Specialty|BCBSTX PPO|||||0.08||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.08||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Cigna|CIGNA|0.08||||0.08||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.08||||0.08||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Managed Medicaid|MEDICAID AMERIGROUP|0.08||||0.08||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Managed Medicaid|MEDICAID SUPERIOR|0.08||||0.08||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.08||||0.08||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.08||||||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.08||||0.08||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|United Medicare Advantage|UHC MEDICARE GOLD MA|0.08||||||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Veterans Affairs|VETERANS ADMINISTRATION|0.08||||0.08||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Managed Medicare|HEALTHSPRING MA|0.08||||||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Managed Medicare|WELLCARE CHOICE MA|||||0.08||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Humana Medicare Advantage|HUMANA MA|0.08||||0.08||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.08||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.08||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Medicaid|MEDICAID|0.08||||0.08||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.08||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||0.08||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Medicaid|MEDICAID TEXAS CHILDRENS|||||0.08||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|NON CONTRACTED|COMMERCIAL OTHER 1|0.08||||0.08||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||0.08||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Medicare|MEDICARE ACUTE|0.08||||0.08||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||0.08||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||0.08||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|United Healthcare|UNITED HEALTHCARE OTHER|||||0.08||| 9506700|ERX|0250|ALBUTEROL 0.5% SOLN 0.5M|United Healthcare|UNITED HEALTHCARE|0.08||||0.08||| 9506726|ERX|0250|METHYLNALTREXONE 12MG/0.6|Medicare|MEDICARE ACUTE|356.75||||||| 9506726|ERX|0250|METHYLNALTREXONE 12MG/0.6|United Medicare Advantage|UHC MEDICARE GOLD MA|356.75||||||| 9506726|ERX|0250|METHYLNALTREXONE 12MG/0.6|Humana Medicare Advantage|HUMANA MA|356.75||||||| 9506775|ERX|0250|CYANOCOBALAMIN 1000MCG/ML|Humana Medicare Advantage|HUMANA MA|0.15||||||| 9506775|ERX|0250|CYANOCOBALAMIN 1000MCG/ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.15||| 9506775|ERX|0250|CYANOCOBALAMIN 1000MCG/ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.15||| 9506775|ERX|0250|CYANOCOBALAMIN 1000MCG/ML|Medicaid|MEDICAID|0.15||||||| 9506809|ERX|0250|AMIODARONE 200MG TABLET|Medicare|MEDICARE ACUTE|46.25||||46.25||| 9506809|ERX|0250|AMIODARONE 200MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|46.25||||||| 9506809|ERX|0250|AMIODARONE 200MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||46.25||| 9506809|ERX|0250|AMIODARONE 200MG TABLET|Humana Medicare Advantage|HUMANA MA|46.25||||46.25||| 9506817|ERX|0250|ATROPINE 0.4MG/ML|Managed Medicaid|MEDICAID AMERIGROUP|||||12.50||| 9506817|ERX|0250|ATROPINE 0.4MG/ML|United Healthcare|UNITED HEALTHCARE|||||12.50||| 9506833|ERX|0250|ATROPINE 1MG/ML, 2ML VIAL|Medicare|MEDICARE ACUTE|12.50||||||| 9506833|ERX|0250|ATROPINE 1MG/ML, 2ML VIAL|Veterans Affairs|VETERANS ADMINISTRATION|12.50||||||| 9506833|ERX|0250|ATROPINE 1MG/ML, 2ML VIAL|Humana Medicare Advantage|HUMANA MA|||||12.50||| 9506833|ERX|0250|ATROPINE 1MG/ML, 2ML VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||12.50||| 9506833|ERX|0250|ATROPINE 1MG/ML, 2ML VIAL|Managed Medicaid|MEDICAID SUPERIOR|12.50||||||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|467.40||||||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|Humana Medicare Advantage|HUMANA MA|467.40||||||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|Managed Medicaid|MEDICAID AMERIGROUP|||||467.40||| 9506841|ERX|0250|VASOPRESSIN 20 UNIT/1ML|Medicare|MEDICARE ACUTE|467.40||||||| 9506890|ERX|0250|CALCIUM CHLORIDE 10% 100M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.22||||||| 9506890|ERX|0250|CALCIUM CHLORIDE 10% 100M|Medicare|MEDICARE ACUTE|0.22||||||| 9506890|ERX|0250|CALCIUM CHLORIDE 10% 100M|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.22||||||| 9506890|ERX|0250|CALCIUM CHLORIDE 10% 100M|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.22||| 9506890|ERX|0250|CALCIUM CHLORIDE 10% 100M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.22||| 9506890|ERX|0250|CALCIUM CHLORIDE 10% 100M|Blue Cross PPO Specialty|BCBSTX PPO|||||0.22||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Blue Cross HMO Specialty|BCBSTX HMO|0.13||||0.13||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Aenta Medicare Advantage|AETNA MEDICARE MA|0.13||||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|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.13||||0.13||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.13||||||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Aetna|AETNA OTHER|||||0.13||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Aetna|AETNA PPO|0.13||||0.13||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Blue Cross PPO Specialty|BCBSTX OTHER|||||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|Cigna|CIGNA|||||0.13||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Cigna|CIGNA|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||||0.13||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Managed Medicaid|MEDICAID AMERIGROUP|0.13||||0.13||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.13||||0.13||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Managed Medicaid|MEDICAID SUPERIOR|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|UHC MEDICARE SOLUTIONS MA|0.13||||0.13||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.13||||0.13||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.13||||0.13||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|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|Workers Compensation|UT EMPLOYEE INJURY|0.13||||||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Workers Compensation|WORKERS COMPENSATION OTHER|0.13||||0.13||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||0.13||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|NON CONTRACTED|COMMERCIAL OTHER 1|0.13||||0.13||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|United Healthcare|UMR UNITED MEDICAL RESOURCES|0.13||||||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|United Healthcare|UNITED HEALTHCARE OTHER|||||0.13||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Rusk State Hospital|RUSK STATE HOSP|0.13||||0.13||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Medicare|MEDICARE ACUTE|0.13||||0.13||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Tricare|TRICARE EAST REGION|0.13||||0.13||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|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|United Healthcare|UNITED HEALTHCARE|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|MEDICARE ADVANTAGE OTHER MA|||||0.13||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Managed Medicare|HEALTHSPRING MA|0.13||||||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Medicaid|MEDICAID|0.13||||0.13||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.13||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Medicaid|MEDICAID TEXAS CHILDRENS|||||0.13||| 9506940|ERX|0250|DEXAMETHASONE 4MG/ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.13||||||| 9506965|ERX|0250|HYDROXYZINE HCL 50MG/1ML|Medicare|MEDICARE ACUTE|12.50||||||| 9506965|ERX|0250|HYDROXYZINE HCL 50MG/1ML|United Healthcare|UNITED HEALTHCARE OTHER|||||12.50||| 9506965|ERX|0250|HYDROXYZINE HCL 50MG/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||12.50||| 9506965|ERX|0250|HYDROXYZINE HCL 50MG/1ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||12.50||| 9506965|ERX|0250|HYDROXYZINE HCL 50MG/1ML|Cigna|CIGNA|||||12.50||| 9506965|ERX|0250|HYDROXYZINE HCL 50MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||12.50||| 9506965|ERX|0250|HYDROXYZINE HCL 50MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|||||12.50||| 9506999|ERX|0250|ACETYLCYSTEINE 20%, 4ML V|Aenta Medicare Advantage|AETNA MEDICARE MA|71.25||||||| 9506999|ERX|0250|ACETYLCYSTEINE 20%, 4ML V|Blue Cross HMO Specialty|BCBSTX HMO|71.25||||||| 9506999|ERX|0250|ACETYLCYSTEINE 20%, 4ML V|Blue Cross PPO Specialty|BCBSTX PPO|71.25||||||| 9506999|ERX|0250|ACETYLCYSTEINE 20%, 4ML V|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|71.25||||||| 9506999|ERX|0250|ACETYLCYSTEINE 20%, 4ML V|Humana Medicare Advantage|HUMANA MA|71.25||||||| 9506999|ERX|0250|ACETYLCYSTEINE 20%, 4ML V|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|71.25||||||| 9506999|ERX|0250|ACETYLCYSTEINE 20%, 4ML V|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|71.25||||||| 9506999|ERX|0250|ACETYLCYSTEINE 20%, 4ML V|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|71.25||||||| 9506999|ERX|0250|ACETYLCYSTEINE 20%, 4ML V|Managed Medicare|HEALTHSPRING MA|71.25||||||| 9506999|ERX|0250|ACETYLCYSTEINE 20%, 4ML V|NON CONTRACTED|COMMERCIAL OTHER 1|71.25||||||| 9506999|ERX|0250|ACETYLCYSTEINE 20%, 4ML V|Medicare|MEDICARE ACUTE|71.25||||||| 9507005|ERX|0250|TRACE ELEMENTS 10ML|Managed Medicare|HEALTHSPRING MA|60.50||||||| 9507039|ERX|0250|PRIMIDONE 50MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||8.50||| 9507039|ERX|0250|PRIMIDONE 50MG TABLET|Medicare|MEDICARE ACUTE|||||8.50||| 9507039|ERX|0250|PRIMIDONE 50MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|8.50||||||| 9507039|ERX|0250|PRIMIDONE 50MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|8.50||||||| 9507054|ERX|0250|ALUMINUM HYDROXIDE 320MG/|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.58||||||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|Managed Medicare|HOSPICE OF EAST TEXAS|28.75||||||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|Medicare|MEDICARE ACUTE|28.75||||||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|Workers Compensation|UT EMPLOYEE INJURY|28.75||||||| 9507088|ERX|0250|PHENOL-SOD PHENOLATE, 180|Aenta Medicare Advantage|AETNA MEDICARE MA|28.75||||||| 9507195|ERX|0250|LIDOCAINE 2% URO-JET 10ML|Humana Medicare Advantage|HUMANA MA|||||86.75||| 9507195|ERX|0250|LIDOCAINE 2% URO-JET 10ML|Blue Cross PPO Specialty|BCBSTX PPO|||||86.75||| 9507195|ERX|0250|LIDOCAINE 2% URO-JET 10ML|Blue Cross PPO Specialty|BCBSTX OTHER|||||86.75||| 9507195|ERX|0250|LIDOCAINE 2% URO-JET 10ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||86.75||| 9507195|ERX|0250|LIDOCAINE 2% URO-JET 10ML|Medicare|MEDICARE ACUTE|86.75||||86.75||| 9507211|ERX|0250|NALOXONE 1MG/ML, 2ML|Medicare|MEDICARE ACUTE|1.15||||1.15||| 9507211|ERX|0250|NALOXONE 1MG/ML, 2ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.15||||||| 9507211|ERX|0250|NALOXONE 1MG/ML, 2ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.15||| 9507211|ERX|0250|NALOXONE 1MG/ML, 2ML|Blue Cross HMO Specialty|BCBSTX HMO|||||1.15||| 9507211|ERX|0250|NALOXONE 1MG/ML, 2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1.15||| 9507229|ERX|0250|OLANZAPINE 10MG ODT TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.41||||||| 9507229|ERX|0250|OLANZAPINE 10MG ODT TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.41||||||| 9507229|ERX|0250|OLANZAPINE 10MG ODT TABLE|Medicaid|MEDICAID|1.41||||||| 9507229|ERX|0250|OLANZAPINE 10MG ODT TABLE|Rusk State Hospital|RUSK STATE HOSP|1.41||||||| 9507229|ERX|0250|OLANZAPINE 10MG ODT TABLE|Medicare|MEDICARE ACUTE|1.41||||||| 9507229|ERX|0250|OLANZAPINE 10MG ODT TABLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.41||||||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|16.75||||||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|Medicare|MEDICARE ACUTE|16.75||||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|Veterans Affairs|VETERANS ADMINISTRATION|16.75||||||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|16.75||||||| 9507294|ERX|0250|ALPRAZOLAM 0.25MG TABLET|Humana Medicare Advantage|HUMANA MA|16.75||||||| 9507351|ERX|0250|CHARCOAL-SORBITOL 25 G, 1|Blue Cross PPO Specialty|BCBSTX PPO|153.25||||||| 9507351|ERX|0250|CHARCOAL-SORBITOL 25 G, 1|Medicare|MEDICARE ACUTE|153.25||||||| 9507377|ERX|0250|CHARCOAL AQ 25 G, 120ML|Medicare|MEDICARE ACUTE|153.25||||||| 9507377|ERX|0250|CHARCOAL AQ 25 G, 120ML|Managed Medicaid|MEDICAID AMERIGROUP|||||153.25||| 9507377|ERX|0250|CHARCOAL AQ 25 G, 120ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||153.25||| 9507385|ERX|0250|HYDROCORTISONE 10MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.09||||||| 9507385|ERX|0250|HYDROCORTISONE 10MG TABLE|Medicare|MEDICARE ACUTE|0.09||||||| 9507393|ERX|0250|CHARCOAL AQ 50 G, 240ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||216.75||| 9507393|ERX|0250|CHARCOAL AQ 50 G, 240ML|Managed Medicaid|MEDICAID AMERIGROUP|||||216.75||| 9507427|ERX|0250|ASPIRIN 300MG SUPP|Medicare|MEDICARE ACUTE|11.50||||||| 9507435|ERX|0250|ASPIRIN 600MG SUPP|United Medicare Advantage|AARP UHC WEST COMPLETE MA|11.50||||||| 9507435|ERX|0250|ASPIRIN 600MG SUPP|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|11.50||||||| 9507492|ERX|0250|DICYCLOMINE 10MG CAPSULE|Medicaid|MEDICAID|0.05||||||| 9507492|ERX|0250|DICYCLOMINE 10MG CAPSULE|Medicare|MEDICARE ACUTE|0.05||||0.05||| 9507492|ERX|0250|DICYCLOMINE 10MG CAPSULE|Humana Medicare Advantage|HUMANA MA|0.05||||||| 9507492|ERX|0250|DICYCLOMINE 10MG CAPSULE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||0.05||| 9507492|ERX|0250|DICYCLOMINE 10MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|||||0.05||| 9507492|ERX|0250|DICYCLOMINE 10MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.05||||||| 9507492|ERX|0250|DICYCLOMINE 10MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|||||0.05||| 9507492|ERX|0250|DICYCLOMINE 10MG CAPSULE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.05||||||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||6.75||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|Managed Medicaid|MEDICAID SUPERIOR|||||6.75||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|Humana Medicare Advantage|HUMANA MA|6.75||||6.75||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||6.75||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|NON CONTRACTED|COMMERCIAL OTHER 1|||||6.75||| 9507575|ERX|0250|METHOCARBAMOL 500MG TABLE|Medicare|MEDICARE ACUTE|6.75||||6.75||| 9507641|ERX|0250|IPRATROP-ALBUTEROL INH,14|United Medicare Advantage|AARP UHC WEST COMPLETE MA|13.95||||||| 9507641|ERX|0250|IPRATROP-ALBUTEROL INH,14|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|13.95||||||| 9507641|ERX|0250|IPRATROP-ALBUTEROL INH,14|Workers Compensation|WORKERS COMPENSATION OTHER|13.95||||||| 9507641|ERX|0250|IPRATROP-ALBUTEROL INH,14|Workers Compensation|UT EMPLOYEE INJURY|13.95||||||| 9507641|ERX|0250|IPRATROP-ALBUTEROL INH,14|Aenta Medicare Advantage|AETNA MEDICARE MA|13.95||||||| 9507641|ERX|0250|IPRATROP-ALBUTEROL INH,14|Blue Cross HMO Specialty|BCBSTX HMO|13.95||||||| 9507641|ERX|0250|IPRATROP-ALBUTEROL INH,14|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|13.95||||||| 9507641|ERX|0250|IPRATROP-ALBUTEROL INH,14|Aetna|AETNA PPO|||||13.95||| 9507641|ERX|0250|IPRATROP-ALBUTEROL INH,14|Blue Cross PPO Specialty|BCBSTX PPO|13.95||||13.95||| 9507641|ERX|0250|IPRATROP-ALBUTEROL INH,14|Managed Medicaid|MEDICAID SUPERIOR|13.95||||||| 9507641|ERX|0250|IPRATROP-ALBUTEROL INH,14|Humana Medicare Advantage|HUMANA MA|13.95||||||| 9507641|ERX|0250|IPRATROP-ALBUTEROL INH,14|Managed Medicaid|MEDICAID UNITED HEALTHCARE|13.95||||13.95||| 9507641|ERX|0250|IPRATROP-ALBUTEROL INH,14|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|13.95||||||| 9507641|ERX|0250|IPRATROP-ALBUTEROL INH,14|United Medicare Advantage|UHC MEDICARE GOLD MA|13.95||||||| 9507641|ERX|0250|IPRATROP-ALBUTEROL INH,14|United Healthcare|UNITED HEALTHCARE|13.95||||||| 9507641|ERX|0250|IPRATROP-ALBUTEROL INH,14|Medicaid|MEDICAID|13.95||||||| 9507641|ERX|0250|IPRATROP-ALBUTEROL INH,14|NON CONTRACTED|COMMERCIAL OTHER 1|13.95||||||| 9507641|ERX|0250|IPRATROP-ALBUTEROL INH,14|Managed Medicare|HEALTHSPRING MA|13.95||||||| 9507641|ERX|0250|IPRATROP-ALBUTEROL INH,14|UTMB|UTMB CORRECTIONAL MANAGED CARE|13.95||||||| 9507641|ERX|0250|IPRATROP-ALBUTEROL INH,14|Medicare|MEDICARE ACUTE|13.95||||13.95||| 9507641|ERX|0250|IPRATROP-ALBUTEROL INH,14|Medicaid|COUNTY INDIGENT HEALTH OTHER|13.95||||||| 9507641|ERX|0250|IPRATROP-ALBUTEROL INH,14|Rusk State Hospital|RUSK STATE HOSP|13.95||||||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|40.50||||||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|Humana Medicare Advantage|HUMANA MA|40.50||||||| 9507666|ERX|0250|MELOXICAM 7.5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|40.50||||||| 9507674|ERX|0250|CLONIDINE 0.1MG PATCH|Medicare|MEDICARE ACUTE|217.50||||||| 9507682|ERX|0250|CLONIDINE 0.2MG PATCH|Medicare|MEDICARE ACUTE|403.25||||||| 9507690|ERX|0250|CLONIDINE 0.3MG PATCH|Blue Cross PPO Specialty|BCBSTX PPO|||||610.50||| 9507690|ERX|0250|CLONIDINE 0.3MG PATCH|Medicare|MEDICARE ACUTE|||||610.50||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|31.25||||||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|31.25||||||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Medicaid|COUNTY INDIGENT HEALTH OTHER|31.25||||||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|||||31.25||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|31.25||||31.25||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|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|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|31.25||||31.25||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|UTMB|UTMB CORRECTIONAL MANAGED CARE|31.25||||||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||31.25||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|31.25||||31.25||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Medicare|MEDICARE ACUTE|31.25||||31.25||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Rusk State Hospital|RUSK STATE HOSP|31.25||||||| 9507716|ERX|0250|TAMSULOSIN 0.4MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|31.25||||||| 9507724|ERX|0250|METHYLPREDNISOLONE 4MG TA|Medicare|MEDICARE ACUTE|17.50||||||| 9507724|ERX|0250|METHYLPREDNISOLONE 4MG TA|Humana Medicare Advantage|HUMANA MA|17.50||||||| 9507773|ERX|0250|IPRATROPIUM INHALER, 12.9|Humana Medicare Advantage|HUMANA MA|1,012.50||||||| 9507773|ERX|0250|IPRATROPIUM INHALER, 12.9|United Medicare Advantage|UHC MEDICARE GOLD MA|1,012.50||||||| 9507773|ERX|0250|IPRATROPIUM INHALER, 12.9|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1,012.50||||1,012.50||| 9507773|ERX|0250|IPRATROPIUM INHALER, 12.9|Medicare|MEDICARE ACUTE|1,012.50||||||| 9507781|ERX|0250|PRAMIPEXOLE 0.125MG TABLE|Humana Medicare Advantage|HUMANA MA|||||24.50||| 9507799|ERX|0250|PRAMIPEXOLE 0.25MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||24.50||| 9507799|ERX|0250|PRAMIPEXOLE 0.25MG TABLET|Medicare|MEDICARE ACUTE|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|Humana Medicare Advantage|HUMANA MA|24.50||||||| 9507799|ERX|0250|PRAMIPEXOLE 0.25MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|24.50||||||| 9507880|ERX|0250|K CHLORIDE 20MEQ/15ML,30M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|7.75||||||| 9507880|ERX|0250|K CHLORIDE 20MEQ/15ML,30M|Medicare|MEDICARE ACUTE|7.75||||||| 9507922|ERX|0250|COLCHICINE 0.6MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|||||5.25||| 9507922|ERX|0250|COLCHICINE 0.6MG TABLET|Humana Medicare Advantage|HUMANA MA|||||5.25||| 9507922|ERX|0250|COLCHICINE 0.6MG TABLET|Medicare|MEDICARE ACUTE|||||5.25||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Workers Compensation|UT EMPLOYEE INJURY|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|Medicare|MEDICARE ACUTE|13.75||||13.75||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Managed Medicaid|MEDICAID SUPERIOR|||||13.75||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||13.75||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|13.75||||||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|Blue Cross PPO Specialty|BCBSTX PPO|||||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 AMERIGROUP|||||13.75||| 9507930|ERX|0250|HYDROXYZINE HCL 25MG TABL|UTMB|UTMB CORRECTIONAL MANAGED CARE|13.75||||13.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|27.75||||27.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||27.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Medicare|MEDICARE ACUTE|||||27.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Rusk State Hospital|RUSK STATE HOSP|27.75||||27.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||27.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Tricare|TRICARE EAST REGION|||||27.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||27.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|27.75||||27.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||27.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Managed Medicaid|MEDICAID AMERIGROUP|||||27.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Cigna|CIGNA|||||27.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Blue Cross PPO Specialty|BCBSTX PPO|||||27.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||27.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Blue Cross HMO Specialty|BCBSTX HMO|27.75||||||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Humana Medicare Advantage|HUMANA MA|27.75||||27.75||| 9508110|ERX|0250|DEXAMETHASONE 10MG/ML|Managed Medicaid|MEDICAID SUPERIOR|||||27.75||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|12.50||||||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Managed Medicare|HEALTHSPRING MA|||||12.50||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|United Healthcare|UNITED HEALTHCARE|12.50||||12.50||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|United Healthcare|UNITED HEALTHCARE|||||12.50||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Rusk State Hospital|RUSK STATE HOSP|||||12.50||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Medicare|MEDICARE ACUTE|12.50||||12.50||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|NON CONTRACTED|COMMERCIAL OTHER 1|12.50||||12.50||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|United Healthcare|UNITED HEALTHCARE OTHER|12.50||||12.50||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||12.50||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Medicaid|MEDICAID|12.50||||12.50||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|12.50||||12.50||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||12.50||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Blue Cross HMO Specialty|BCBSTX HMO|12.50||||12.50||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||12.50||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||12.50||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||12.50||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Humana Medicare Advantage|HUMANA MA|12.50||||12.50||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12.50||||12.50||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|12.50||||12.50||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Tricare|TRICARE EAST REGION|||||12.50||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Aetna|AETNA PPO|||||12.50||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|12.50||||||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||12.50||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Blue Cross PPO Specialty|BCBSTX OTHER|||||12.50||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|12.50||||12.50||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Managed Medicaid|MEDICAID AMERIGROUP|12.50||||12.50||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|12.50||||12.50||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Blue Cross PPO Specialty|BCBSTX PPO|12.50||||12.50||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Managed Medicaid|MEDICAID SUPERIOR|12.50||||12.50||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Cigna|CIGNA|||||12.50||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Veterans Affairs|VETERANS ADMINISTRATION|||||12.50||| 9508128|ERX|0250|DIPHENHYDRAMINE 50MG/ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|12.50||||12.50||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|12.50||||||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|12.50||||12.50||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|12.50||||||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Blue Cross PPO Specialty|BCBSTX PPO|12.50||||||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Blue Cross HMO Specialty|BCBSTX HMO|12.50||||12.50||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|12.50||||||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Workers Compensation|WORKERS COMPENSATION OTHER|12.50||||||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|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|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|12.50||||12.50||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Managed Medicare|HEALTHSPRING MA|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|Rusk State Hospital|RUSK STATE HOSP|12.50||||||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|United Healthcare|UNITED HEALTHCARE|||||12.50||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Workers Compensation|UT EMPLOYEE INJURY|12.50||||||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|12.50||||12.50||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|12.50||||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|UTMB|UTMB CORRECTIONAL MANAGED CARE|12.50||||||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Medicaid|MEDICAID|12.50||||12.50||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Medicare|MEDICARE ACUTE|12.50||||12.50||| 9508144|ERX|0250|HEPARIN 5000 UNIT/1ML|Veterans Affairs|VETERANS ADMINISTRATION|12.50||||12.50||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Cigna|CIGNA|||||0.37||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.37||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.37||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||0.37||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|United Healthcare|UNITED HEALTHCARE|||||0.37||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.37||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Veterans Affairs|VETERANS ADMINISTRATION|0.37||||||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.37||||||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.37||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Aetna|AETNA PPO|||||0.37||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Blue Cross PPO Specialty|BCBSTX PPO|||||0.37||| 9508177|ERX|0250|PROCHLORPERAZINE 5MG/ML,|Medicare|MEDICARE ACUTE|0.37||||0.37||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Cigna|CIGNA|||||19.75||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Humana Medicare Advantage|HUMANA MA|||||19.75||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Medicare|MEDICARE ACUTE|19.75||||19.75||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|19.75||||19.75||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|19.75||||19.75||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Blue Cross HMO Specialty|BCBSTX HMO|19.75||||19.75||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Managed Medicaid|MEDICAID AMERIGROUP|19.75||||19.75||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Aetna|AETNA PPO|19.75||||||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|19.75||||19.75||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|19.75||||19.75||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|19.75||||19.75||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Managed Medicare|HEALTHSPRING MA|19.75||||||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Aetna|AETNA OTHER|||||19.75||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|19.75||||19.75||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||19.75||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|19.75||||19.75||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Veterans Affairs|VETERANS ADMINISTRATION|19.75||||||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|United Healthcare|UNITED HEALTHCARE|19.75||||19.75||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Medicaid|MEDICAID|19.75||||19.75||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Managed Medicare|HOSPICE OF EAST TEXAS|19.75||||||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|United Healthcare|UNITED HEALTHCARE OTHER|||||19.75||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|Tricare|TRICARE EAST REGION|19.75||||||| 9508201|ERX|0250|PROMETHAZINE 25MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|19.75||||||| 9508219|ERX|0250|GENTAMICIN 40MG/ML, 20ML|Managed Medicaid|MEDICAID AMERIGROUP|1.24||||||| 9508219|ERX|0250|GENTAMICIN 40MG/ML, 20ML|Managed Medicaid|MEDICAID SUPERIOR|||||1.24||| 9508219|ERX|0250|GENTAMICIN 40MG/ML, 20ML|Blue Cross PPO Specialty|BCBSTX PPO|1.24||||||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|Tricare|TRICARE EAST REGION|||||227.25||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|Medicare|MEDICARE ACUTE|227.25||||||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|Managed Medicaid|MEDICAID SUPERIOR|227.25||||||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|Cigna|CIGNA|||||227.25||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|Managed Medicaid|MEDICAID AMERIGROUP|||||227.25||| 9508235|ERX|0250|ESMOLOL 100MG/10ML|Blue Cross PPO Specialty|BCBSTX PPO|||||227.25||| 9508250|ERX|0250|SODIUM BICARBONATE 650MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||||| 9508250|ERX|0250|SODIUM BICARBONATE 650MG|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9508250|ERX|0250|SODIUM BICARBONATE 650MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||||| 9508268|ERX|0250|FERROUS SULFATE 220MG 5ML|Medicare|MEDICARE ACUTE|7.50||||||| 9508367|ERX|0250|GLYCERIN, PEDIATRIC SUPP|Blue Cross PPO Specialty|BCBSTX PPO|2.75||||2.75||| 9508367|ERX|0250|GLYCERIN, PEDIATRIC SUPP|Managed Medicaid|MEDICAID AMERIGROUP|||||2.75||| 9508367|ERX|0250|GLYCERIN, PEDIATRIC SUPP|Managed Medicaid|MEDICAID SUPERIOR|2.75||||||| 9508367|ERX|0250|GLYCERIN, PEDIATRIC SUPP|Medicaid|MEDICAID HMO|||||2.75||| 9508367|ERX|0250|GLYCERIN, PEDIATRIC SUPP|Medicaid|MOLINA HEALTHCARE OF TEXAS|2.75||||||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Managed Medicaid|MEDICAID AMERIGROUP|38.50||||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|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|38.50||||||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Rusk State Hospital|RUSK STATE HOSP|38.50||||||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||38.50||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Medicare|MEDICARE ACUTE|38.50||||38.50||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|38.50||||38.50||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Medicaid|MEDICAID|38.50||||38.50||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|UTMB|UTMB CORRECTIONAL MANAGED CARE|38.50||||||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Medicaid|COUNTY INDIGENT HEALTH OTHER|38.50||||||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|United Medicare Advantage|AARP UHC WEST COMPLETE 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 SUPERIOR|38.50||||38.50||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|38.50||||||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|NON CONTRACTED|COMMERCIAL OTHER 1|38.50||||||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Aenta Medicare Advantage|AETNA MEDICARE MA|38.50||||||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Blue Cross HMO Specialty|BCBSTX HMO|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|Blue Cross PPO Specialty|BCBSTX OTHER|38.50||||||| 9508375|ERX|0250|METHYLPREDNISOLONE 40MG/1|Veterans Affairs|VETERANS ADMINISTRATION|38.50||||||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.25||||4.25||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.25||||4.25||| 9508383|ERX|0250|BISACODYL 10MG SUPP|United Medicare Advantage|UHC MEDICARE GOLD MA|||||4.25||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||4.25||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Managed Medicaid|MEDICAID SUPERIOR|||||4.25||| 9508383|ERX|0250|BISACODYL 10MG SUPP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||4.25||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Humana Medicare Advantage|HUMANA MA|4.25||||4.25||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||4.25||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Blue Cross PPO Specialty|BCBSTX PPO|||||4.25||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Medicare|MEDICARE ACUTE|4.25||||4.25||| 9508383|ERX|0250|BISACODYL 10MG SUPP|United Medicare Advantage|AARP UHC WEST COMPLETE MA|4.25||||||| 9508383|ERX|0250|BISACODYL 10MG SUPP|Rusk State Hospital|RUSK STATE HOSP|||||4.25||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|Managed Medicare|HOSPICE OF EAST TEXAS|0.09||||||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.09||||||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|Medicaid|MEDICAID|||||0.09||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|Medicare|MEDICARE ACUTE|0.09||||||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|Humana Medicare Advantage|HUMANA MA|0.09||||||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.09||||||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|Aenta Medicare Advantage|AETNA MEDICARE MA|||||0.09||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.09||||||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|Managed Medicaid|MEDICAID SUPERIOR|||||0.09||| 9508409|ERX|0250|ACETAMINOPHEN 650MG SUPP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.09||||||| 9508417|ERX|0250|HYDROCORTISONE 25MG SUPP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.14||| 9508417|ERX|0250|HYDROCORTISONE 25MG SUPP|Humana Medicare Advantage|HUMANA MA|0.14||||||| 9508417|ERX|0250|HYDROCORTISONE 25MG SUPP|Workers Compensation|UT EMPLOYEE INJURY|||||0.14||| 9508433|ERX|0250|FLUOXETINE 10MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.56||| 9508433|ERX|0250|FLUOXETINE 10MG CAPSULE|Medicare|MEDICARE ACUTE|0.56||||||| 9508433|ERX|0250|FLUOXETINE 10MG CAPSULE|Medicaid|MEDICAID|0.56||||||| 9508433|ERX|0250|FLUOXETINE 10MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|0.56||||||| 9508433|ERX|0250|FLUOXETINE 10MG CAPSULE|Humana Medicare Advantage|HUMANA MA|0.56||||||| 9508433|ERX|0250|FLUOXETINE 10MG CAPSULE|Aetna|AETNA OTHER|0.56||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.57||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Humana Medicare Advantage|HUMANA MA|0.57||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|0.57||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Medicare|MEDICARE ACUTE|0.57||||0.57||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.57||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|0.57||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|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|Rusk State Hospital|RUSK STATE HOSP|0.57||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|0.57||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Medicaid|MEDICAID|0.57||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|0.57||||||| 9508441|ERX|0250|FLUOXETINE 20MG CAPSULE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||0.57||| 9508565|ERX|0250|HALOPERIDOL 5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|14.50||||||| 9508565|ERX|0250|HALOPERIDOL 5MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|14.50||||||| 9508565|ERX|0250|HALOPERIDOL 5MG TABLET|Medicare|MEDICARE ACUTE|14.50||||||| 9508565|ERX|0250|HALOPERIDOL 5MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|||||14.50||| 9508565|ERX|0250|HALOPERIDOL 5MG TABLET|Humana Medicare Advantage|HUMANA MA|14.50||||||| 9508565|ERX|0250|HALOPERIDOL 5MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|14.50||||||| 9508565|ERX|0250|HALOPERIDOL 5MG TABLET|Rusk State Hospital|RUSK STATE HOSP|14.50||||||| 9508656|ERX|0250|CLINDAMYCIN 150MG CAPSULE|Medicare|MEDICARE ACUTE|||||0.37||| 9508656|ERX|0250|CLINDAMYCIN 150MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.37||| 9508656|ERX|0250|CLINDAMYCIN 150MG CAPSULE|United Healthcare|UNITED HEALTHCARE OTHER|||||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 AMERIGROUP|||||0.37||| 9508656|ERX|0250|CLINDAMYCIN 150MG CAPSULE|Managed Medicare|HEALTHSPRING MA|0.37||||||| 9508656|ERX|0250|CLINDAMYCIN 150MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|||||0.37||| 9508656|ERX|0250|CLINDAMYCIN 150MG CAPSULE|Humana Medicare Advantage|HUMANA MA|0.37||||||| 9508656|ERX|0250|CLINDAMYCIN 150MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||0.37||| 9508656|ERX|0250|CLINDAMYCIN 150MG CAPSULE|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.37||| 9508656|ERX|0250|CLINDAMYCIN 150MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|||||0.37||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Blue Cross PPO Specialty|BCBSTX PPO|||||150.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|NON CONTRACTED|COMMERCIAL OTHER 1|||||150.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Medicare|MEDICARE ACUTE|||||150.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|United Healthcare|UNITED HEALTHCARE|||||150.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|150.50||||150.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Aetna|AETNA OTHER|||||150.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||150.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|Humana Medicare Advantage|HUMANA MA|150.50||||150.50||| 9508722|ERX|0250|BACITRACIN 50000 UNIT VIA|United Medicare Advantage|UHC MEDICARE GOLD MA|150.50||||150.50||| 9508755|ERX|0250|VITAMIN E 1000 UNIT CAPSU|Aenta Medicare Advantage|AETNA MEDICARE MA|||||2.75||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|7.50||||||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|Medicaid|MEDICAID|7.50||||||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||7.50||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|United Healthcare|UMR UNITED MEDICAL RESOURCES|7.50||||||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.50||||||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||7.50||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.50||||||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|7.50||||||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|Humana Medicare Advantage|HUMANA MA|7.50||||||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|7.50||||7.50||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|Medicare|MEDICARE ACUTE|7.50||||||| 9508821|ERX|0250|BACLOFEN 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.50||||||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|||||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|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.07||||0.07||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.07||||0.07||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Cigna|CIGNA|0.07||||||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.07||||0.07||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.07||||0.07||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.07||||||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Humana Medicare Advantage|HUMANA MA|||||0.07||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|0.07||||0.07||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|0.07||||0.07||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Tricare|TRICARE EAST REGION|0.07||||||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.07||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|United Healthcare|UNITED HEALTHCARE|0.07||||||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Medicare|MEDICARE ACUTE|0.07||||0.07||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.07||||||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|0.07||||||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|0.07||||||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.07||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Medicaid|MEDICAID|0.07||||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||| 9508854|ERX|0250|IBUPROFEN 800MG TABLET|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.07||||||| 9508862|ERX|0250|GEMFIBROZIL 600MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.15||||||| 9508862|ERX|0250|GEMFIBROZIL 600MG TABLET|Medicare|MEDICARE ACUTE|0.15||||||| 9508995|ERX|0250|METHYLPREDNIS DEPO 40MG/M|Workers Compensation|WORKERS COMPENSATION OTHER|||||3.14||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Medicare|MEDICARE ACUTE|||||306.75||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Medicaid|MEDICAID|||||306.75||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Medicaid|MEDICAID HMO|||||306.75||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|United Healthcare|UNITED HEALTHCARE OTHER|||||306.75||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||306.75||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|NON CONTRACTED|COMMERCIAL OTHER 2|||||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||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|United Healthcare|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|Blue Cross PPO Specialty|BCBSTX PPO|||||306.75||| 9509068|ERX|0250|PROPARACAINE 0.5% DROP,15|Tricare|TRICARE EAST REGION|||||306.75||| 9509084|ERX|0250|METHYLPRED DEPO 40MG/ML,1|Workers Compensation|WORKERS COMPENSATION OTHER|||||514.75||| 9509134|ERX|0250|ATROPINE 1% EYE DROP, 5ML|Humana Medicare Advantage|HUMANA MA|236.50||||||| 9509134|ERX|0250|ATROPINE 1% EYE DROP, 5ML|Managed Medicare|HOSPICE OF EAST TEXAS|236.50||||||| 9509134|ERX|0250|ATROPINE 1% EYE DROP, 5ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|236.50||||||| 9509134|ERX|0250|ATROPINE 1% EYE DROP, 5ML|Medicare|MEDICARE ACUTE|236.50||||||| 9509225|ERX|0250|BISMUTH SUBSALIC 262MG TA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||||| 9509266|ERX|0250|MEDROXYPROGESTERONE 5MG T|Managed Medicaid|MEDICAID SUPERIOR|17.50||||||| 9509266|ERX|0250|MEDROXYPROGESTERONE 5MG T|Blue Cross HMO Specialty|BCBSTX HMO|||||17.50||| 9509266|ERX|0250|MEDROXYPROGESTERONE 5MG T|Medicare|MEDICARE ACUTE|17.50||||||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|118.50||||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 DUAL COMPLETE HMO SNP 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|Veterans Affairs|VETERANS ADMINISTRATION|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|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|118.50||||118.50||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||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|Aetna|AETNA PPO|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|Blue Cross PPO Specialty|BCBSTX OTHER|||||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|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||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 AMERIGROUP|118.50||||118.50||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Aetna|AETNA OTHER|||||118.50||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Access Direct Platinum|HEALTHFIRST TPA UMR|||||118.50||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Managed Medicare|HEALTHSPRING MA|118.50||||118.50||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Medicaid|MEDICAID|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 UNITED HEALTHCARE|118.50||||118.50||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Managed Medicare|BCBS MEDICARE PPO MA|||||118.50||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||118.50||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|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|Cigna|CIGNA|||||118.50||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Workers Compensation|WORKERS COMPENSATION OTHER|118.50||||118.50||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||118.50||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Cigna|CIGNA|118.50||||||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|United Healthcare|UNITED HEALTHCARE|118.50||||118.50||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Managed Medicaid|MEDICAID SUPERIOR|118.50||||118.50||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|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|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|118.50||||118.50||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|United Healthcare|UMR UNITED MEDICAL RESOURCES|118.50||||||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|Medicare|MEDICARE ACUTE|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|Tricare|TRICARE EAST REGION|118.50||||118.50||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|118.50||||||| 9509274|ERX|0250|PROPOFOL 200MG/20ML|United Healthcare|UNITED HEALTHCARE OTHER|118.50||||118.50||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|United Healthcare|UNITED HEALTHCARE|12.50||||12.50||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Managed Medicare|HEALTHSPRING MA|12.50||||12.50||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|12.50||||||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|United Healthcare|UMR UNITED MEDICAL RESOURCES|12.50||||||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Medicare|MEDICARE ACUTE|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|Tricare|TRICARE EAST REGION|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 Medicare|BCBS MEDICARE PPO MA|||||12.50||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Cigna|CIGNA|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|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|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|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|12.50||||12.50||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|12.50||||12.50||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|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|Managed Medicaid|MEDICAID UNITED HEALTHCARE|12.50||||12.50||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Aetna|AETNA OTHER|||||12.50||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||12.50||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Aetna|AETNA PPO|12.50||||12.50||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Access Direct Platinum|HEALTHFIRST TPA UMR|||||12.50||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Cigna|CIGNA|||||12.50||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Blue Cross HMO Specialty|BCBSTX HMO|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|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|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|NON CONTRACTED|COMMERCIAL OTHER 1|12.50||||12.50||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|United Healthcare|UNITED HEALTHCARE OTHER|12.50||||12.50||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Blue Cross PPO Specialty|BCBSTX OTHER|||||12.50||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Veterans Affairs|VETERANS ADMINISTRATION|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|Workers Compensation|WORKERS COMPENSATION OTHER|12.50||||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|UHC DUAL COMPLETE HMO SNP MA|12.50||||12.50||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||12.50||| 9509308|ERX|0250|MIDAZOLAM 2MG/2ML|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|12.50||||12.50||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|27.50||||27.50||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|Blue Cross PPO Specialty|BCBSTX PPO|27.50||||27.50||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|Veterans Affairs|VETERANS ADMINISTRATION|||||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|Workers Compensation|WORKERS COMPENSATION OTHER|||||27.50||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|Rusk State Hospital|RUSK STATE HOSP|27.50||||27.50||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|Medicare|MEDICARE ACUTE|27.50||||27.50||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||27.50||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|27.50||||27.50||| 9509316|ERX|0250|MIDAZOLAM 5MG/5ML|Managed Medicaid|MEDICAID SUPERIOR|27.50||||||| 9509324|ERX|0258|ESMOLOL 2500MG/250ML SALI|Managed Medicaid|MEDICAID SUPERIOR|1,568.38||||||| 9509324|ERX|0258|ESMOLOL 2500MG/250ML SALI|Humana Medicare Advantage|HUMANA MA|1,568.38||||||| 9509324|ERX|0258|ESMOLOL 2500MG/250ML SALI|UTMB|UTMB CORRECTIONAL MANAGED CARE|1,568.38||||||| 9509324|ERX|0258|ESMOLOL 2500MG/250ML SALI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,568.38||||||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|United Healthcare|UNITED HEALTHCARE OTHER|||||16.75||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Blue Cross HMO Specialty|BCBSTX HMO|16.75||||16.75||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|16.75||||||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|United Healthcare|UNITED HEALTHCARE|||||16.75||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|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|Blue Cross PPO Specialty|BCBSTX PPO|16.75||||16.75||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Managed Medicaid|MEDICAID AMERIGROUP|||||16.75||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|||||16.75||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||16.75||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Medicare|MEDICARE ACUTE|16.75||||16.75||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|16.75||||16.75||| 9509340|ERX|0250|MEPERIDINE 25MG/1ML|Humana Medicare Advantage|HUMANA MA|16.75||||||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Medicare|MEDICARE ACUTE|16.75||||16.75||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Medicaid|MEDICAID|16.75||||||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|16.75||||16.75||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Tricare|TRICARE EAST REGION|16.75||||||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|16.75||||||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||16.75||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|16.75||||||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Humana Medicare Advantage|HUMANA MA|||||16.75||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|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|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|16.75||||||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Blue Cross HMO Specialty|BCBSTX HMO|16.75||||||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|16.75||||16.75||| 9509357|ERX|0250|MEPERIDINE 50MG/1ML|Cigna|CIGNA|16.75||||||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|40.85||||||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Blue Cross HMO Specialty|BCBSTX HMO|40.85||||40.85||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|United Healthcare|UNITED HEALTHCARE OTHER|||||40.85||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|40.85||||40.85||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|40.85||||||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Cigna|CIGNA|40.85||||||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|40.85||||40.85||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Blue Cross PPO Specialty|BCBSTX OTHER|||||40.85||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|40.85||||40.85||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||40.85||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|40.85||||||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|40.85||||40.85||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Aetna|AETNA OTHER|||||40.85||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Humana Medicare Advantage|HUMANA MA|40.85||||40.85||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Rusk State Hospital|RUSK STATE HOSP|||||40.85||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Medicare|MEDICARE ACUTE|40.85||||40.85||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|40.85||||||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|40.85||||||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Medicaid|MEDICAID|40.85||||40.85||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|40.85||||40.85||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Tricare|TRICARE EAST REGION|||||40.85||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Managed Medicaid|MEDICAID AMERIGROUP|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||||40.85||| 9509399|ERX|0250|PHENYLEPHRINE 10MG/1ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|40.85||||||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|Aenta Medicare Advantage|AETNA MEDICARE MA|0.37||||||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.37||||0.37||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|Medicare|MEDICARE ACUTE|0.37||||0.37||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|Blue Cross PPO Specialty|BCBSTX PPO|||||0.37||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|Humana Medicare Advantage|HUMANA MA|0.37||||0.37||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|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|NON CONTRACTED|COMMERCIAL OTHER 1|0.37||||||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||0.37||| 9509449|ERX|0250|DILTIAZEM 25MG 5ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.37||| 9509456|ERX|0250|METHYLPREDNIS DEPO 80MG/M|Workers Compensation|WORKERS COMPENSATION OTHER|||||514.75||| 9509456|ERX|0250|METHYLPREDNIS DEPO 80MG/M|Blue Cross PPO Specialty|BCBSTX PPO|||||514.75||| 9509456|ERX|0250|METHYLPREDNIS DEPO 80MG/M|Humana Medicare Advantage|HUMANA MA|||||514.75||| 9509456|ERX|0250|METHYLPREDNIS DEPO 80MG/M|Managed Medicaid|MEDICAID SUPERIOR|||||514.75||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||21.50||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Medicare|MEDICARE ACUTE|21.50||||21.50||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Tricare|TRICARE EAST REGION|21.50||||||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Managed Medicaid|MEDICAID SUPERIOR|||||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|Managed Medicaid|MEDICAID AMERIGROUP|21.50||||21.50||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Blue Cross HMO Specialty|BCBSTX HMO|21.50||||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|Aenta Medicare Advantage|AETNA MEDICARE MA|||||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|United Medicare Advantage|AARP UHC WEST COMPLETE MA|21.50||||||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Medicaid|MEDICAID|||||21.50||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||21.50||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||21.50||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|Workers Compensation|WORKERS COMPENSATION OTHER|||||21.50||| 9509472|ERX|0250|CEFAZOLIN 1 G VIAL|United Healthcare|UNITED HEALTHCARE|||||21.50||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|Medicare|MEDICARE ACUTE|24.50||||||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|United Healthcare|UNITED HEALTHCARE|||||24.50||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE 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|Workers Compensation|WORKERS COMPENSATION OTHER|24.50||||||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|24.50||||||| 9509548|ERX|0250|TIZANIDINE 4MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|24.50||||||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Managed Medicare|HEALTHSPRING MA|16.75||||||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Medicare|MEDICARE ACUTE|16.75||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|NON CONTRACTED|COMMERCIAL OTHER 1|16.75||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|16.75||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Managed Medicare|BCBS MEDICARE PPO MA|||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|16.75||||||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Humana Medicare Advantage|HUMANA MA|16.75||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Medicaid|MEDICAID|16.75||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Cigna|CIGNA|||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|16.75||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Cigna|CIGNA|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 AMERIGROUP|16.75||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|16.75||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|16.75||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Aetna|AETNA PPO|16.75||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Access Direct Platinum|HEALTHFIRST TPA UMR|||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Aetna|AETNA OTHER|||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|16.75||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|16.75||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Rusk State Hospital|RUSK STATE HOSP|16.75||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Tricare|TRICARE EAST REGION|16.75||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Aenta Medicare Advantage|AETNA MEDICARE MA|16.75||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Blue Cross PPO Specialty|BCBSTX PPO|16.75||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Blue Cross PPO Specialty|BCBSTX OTHER|||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|United Healthcare|UNITED HEALTHCARE|16.75||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Blue Cross HMO Specialty|BCBSTX HMO|16.75||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|United Healthcare|UNITED HEALTHCARE|||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|United Healthcare|UMR UNITED MEDICAL RESOURCES|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|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|16.75||||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 Healthcare|UNITED HEALTHCARE OTHER|16.75||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Veterans Affairs|VETERANS ADMINISTRATION|16.75||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|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|Workers Compensation|WORKERS COMPENSATION OTHER|16.75||||16.75||| 9509605|ERX|0250|FENTANYL 100MCG/2ML|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||16.75||| 9509654|ERX|0250|METHYLENE BLUE 10MG/1ML|United Healthcare|UNITED HEALTHCARE OTHER|||||1.17||| 9509654|ERX|0250|METHYLENE BLUE 10MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|||||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|Managed Medicaid|MEDICAID SUPERIOR|||||1.17||| 9509654|ERX|0250|METHYLENE BLUE 10MG/1ML|Blue Cross HMO Specialty|BCBSTX HMO|||||1.17||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.50||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Tricare|TRICARE EAST REGION|||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Cigna|CIGNA|||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 2|||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.50||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Medicare|MEDICARE PART B ONLY IP|2.50||||||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Medicaid|MEDICAID|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|Aetna|AETNA PPO|||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||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|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||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|UHC MEDICARE GOLD MA|2.50||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|United Healthcare|UNITED HEALTHCARE|||||2.50||| 9509894|ERX|0250|ASPIRIN 325MG TABLET|United Healthcare|GEHA|||||2.50||| 9509993|ERX|0250|COLESTIPOL 1 G TABLET|Tricare|TRICARE EAST REGION|12.25||||||| 9509993|ERX|0250|COLESTIPOL 1 G TABLET|Medicare|MEDICARE ACUTE|||||12.25||| 951|DRG||OTHER FACTORS INFLUENCING HEALTH STATUS|Managed Medicare|HOSPICE OF EAST TEXAS|9,558.13|6922.25|6922.25|6804.8|||| 951|DRG||OTHER FACTORS INFLUENCING HEALTH STATUS|Humana Medicare Advantage|HUMANA MA|53,392.30|6804.8|6922.25|6804.8|||| 9510041|ERX|0250|SIMETHICONE 40MG/0.6ML, 3|Managed Medicaid|MEDICAID SUPERIOR|106.50||||||| 9510041|ERX|0250|SIMETHICONE 40MG/0.6ML, 3|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|106.50||||||| 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 AMERIGROUP|106.50||||106.50||| 9510041|ERX|0250|SIMETHICONE 40MG/0.6ML, 3|Medicaid|MEDICAID|106.50||||||| 9510116|ERX|0250|OXYBUTYNIN XL 5MG TABLET|United Healthcare|UMR UNITED MEDICAL RESOURCES|40.50||||||| 9510116|ERX|0250|OXYBUTYNIN XL 5MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|40.50||||40.50||| 9510116|ERX|0250|OXYBUTYNIN XL 5MG TABLET|Humana Medicare Advantage|HUMANA MA|40.50||||||| 9510116|ERX|0250|OXYBUTYNIN XL 5MG TABLET|Medicare|MEDICARE ACUTE|40.50||||40.50||| 9510157|ERX|0250|NA CITRATE-CITRIC ACID 30|Medicaid|MEDICAID|0.20||||||| 9510157|ERX|0250|NA CITRATE-CITRIC ACID 30|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.20||| 9510157|ERX|0250|NA CITRATE-CITRIC ACID 30|Blue Cross PPO Specialty|BCBSTX PPO|||||0.20||| 9510157|ERX|0250|NA CITRATE-CITRIC ACID 30|Managed Medicaid|MEDICAID SUPERIOR|0.20||||0.20||| 9510157|ERX|0250|NA CITRATE-CITRIC ACID 30|Humana Medicare Advantage|HUMANA MA|0.20||||0.20||| 9510215|ERX|0250|GENTAMICIN EYE OINT, 3.5G|United Healthcare|UNITED HEALTHCARE|||||194.25||| 9510249|ERX|0250|PROPRANOLOL XL 80MG CAPSU|Medicare|MEDICARE ACUTE|44.75||||||| 9510249|ERX|0250|PROPRANOLOL XL 80MG CAPSU|Blue Cross PPO Specialty|BCBSTX PPO|||||44.75||| 9510256|ERX|0250|MEDROXYPROGEST DEPO 150MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||674.50||| 9510256|ERX|0250|MEDROXYPROGEST DEPO 150MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|674.50||||||| 9510256|ERX|0250|MEDROXYPROGEST DEPO 150MG|Blue Cross PPO Specialty|BCBSTX PPO|||||674.50||| 9510298|ERX|0250|TIMOLOL 0.5% EYE DROP, 5M|Blue Cross HMO Specialty|BCBSTX HMO|1.68||||||| 9510298|ERX|0250|TIMOLOL 0.5% EYE DROP, 5M|Medicare|MEDICARE ACUTE|1.68||||||| 9510298|ERX|0250|TIMOLOL 0.5% EYE DROP, 5M|Humana Medicare Advantage|HUMANA MA|1.68||||||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|United Healthcare|UNITED HEALTHCARE|||||9.50||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|United Healthcare|UNITED HEALTHCARE OTHER|||||9.50||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|United Medicare Advantage|UHC MEDICARE GOLD MA|||||9.50||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||9.50||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|Managed Medicaid|MEDICAID AMERIGROUP|||||9.50||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|Workers Compensation|WORKERS COMPENSATION OTHER|||||9.50||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||9.50||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|Managed Medicaid|MEDICAID SUPERIOR|||||9.50||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||9.50||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|Blue Cross PPO Specialty|BCBSTX PPO|||||9.50||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|Cigna|CIGNA|||||9.50||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|Medicaid|MEDICAID HMO|||||9.50||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|Medicaid|MEDICAID|||||9.50||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|NON CONTRACTED|COMMERCIAL OTHER 2|||||9.50||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|Tricare|TRICARE EAST REGION|||||9.50||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|Humana Medicare Advantage|HUMANA MA|||||9.50||| 9510348|ERX|0250|FLUORESCEIN EYE STRIP|Medicare|MEDICARE ACUTE|||||9.50||| 9510397|ERX|0250|CLINDAMYCIN 75MG/5ML, 100|Managed Medicaid|MEDICAID AMERIGROUP|4.19||||||| 9510397|ERX|0250|CLINDAMYCIN 75MG/5ML, 100|Managed Medicaid|MEDICAID SUPERIOR|||||4.19||| 9510397|ERX|0250|CLINDAMYCIN 75MG/5ML, 100|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.19||||||| 9510405|ERX|0250|SULFACETAMIDE 10% DROP,15|NON CONTRACTED|COMMERCIAL OTHER 2|||||57.75||| 9510405|ERX|0250|SULFACETAMIDE 10% DROP,15|Blue Cross PPO Specialty|BCBSTX PPO|||||57.75||| 9510405|ERX|0250|SULFACETAMIDE 10% DROP,15|Medicare|MEDICARE ACUTE|57.75||||57.75||| 9510405|ERX|0250|SULFACETAMIDE 10% DROP,15|Humana Medicare Advantage|HUMANA MA|||||57.75||| 9510405|ERX|0250|SULFACETAMIDE 10% DROP,15|Cigna|CIGNA|||||57.75||| 9510405|ERX|0250|SULFACETAMIDE 10% DROP,15|Managed Medicaid|MEDICAID SUPERIOR|||||57.75||| 9510405|ERX|0250|SULFACETAMIDE 10% DROP,15|Managed Medicaid|MEDICAID AMERIGROUP|||||57.75||| 9510470|ERX|0250|CLINDAMYCIN 600MG 4ML|Humana Medicare Advantage|HUMANA MA|||||1.14||| 9510470|ERX|0250|CLINDAMYCIN 600MG 4ML|Managed Medicaid|MEDICAID SUPERIOR|1.14||||||| 9510470|ERX|0250|CLINDAMYCIN 600MG 4ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1.14||| 9510470|ERX|0250|CLINDAMYCIN 600MG 4ML|Blue Cross PPO Specialty|BCBSTX PPO|1.14||||1.14||| 9510470|ERX|0250|CLINDAMYCIN 600MG 4ML|Managed Medicaid|MEDICAID AMERIGROUP|||||1.14||| 9510470|ERX|0250|CLINDAMYCIN 600MG 4ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.14||||1.14||| 9510470|ERX|0250|CLINDAMYCIN 600MG 4ML|Medicare|MEDICARE ACUTE|||||1.14||| 9510470|ERX|0250|CLINDAMYCIN 600MG 4ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||1.14||| 9510587|ERX|0250|PSYLLIUM SEED (SUGAR FREE|United Medicare Advantage|UHC MEDICARE GOLD MA|0.05||||||| 9510587|ERX|0250|PSYLLIUM SEED (SUGAR FREE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.05||||||| 9510587|ERX|0250|PSYLLIUM SEED (SUGAR FREE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.05||||||| 9510587|ERX|0250|PSYLLIUM SEED (SUGAR FREE|Veterans Affairs|VETERANS ADMINISTRATION|0.05||||||| 9510587|ERX|0250|PSYLLIUM SEED (SUGAR FREE|Aenta Medicare Advantage|AETNA MEDICARE MA|0.05||||||| 9510587|ERX|0250|PSYLLIUM SEED (SUGAR FREE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.05||||||| 9510587|ERX|0250|PSYLLIUM SEED (SUGAR FREE|Medicare|MEDICARE ACUTE|0.05||||||| 9510587|ERX|0250|PSYLLIUM SEED (SUGAR FREE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.05||||||| 9510587|ERX|0250|PSYLLIUM SEED (SUGAR FREE|Brinson Benefits|THE HEALTH PLAN SMITH CO|0.05||||||| 9510587|ERX|0250|PSYLLIUM SEED (SUGAR FREE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.05||||||| 9510587|ERX|0250|PSYLLIUM SEED (SUGAR FREE|Humana Medicare Advantage|HUMANA MA|0.05||||||| 9510637|ERX|0250|TOBRAMYCIN 1.2 G VIAL|Medicare|MEDICARE ACUTE|2,672.50||||||| 9510678|ERX|0250|AMMONIA AROMATIC AMPULE|Humana Medicare Advantage|HUMANA MA|||||9.50||| 9510678|ERX|0250|AMMONIA AROMATIC AMPULE|Managed Medicaid|MEDICAID SUPERIOR|||||9.50||| 9510678|ERX|0250|AMMONIA AROMATIC AMPULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||9.50||| 9510678|ERX|0250|AMMONIA AROMATIC AMPULE|Blue Cross PPO Specialty|BCBSTX PPO|||||9.50||| 9510678|ERX|0250|AMMONIA AROMATIC AMPULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||9.50||| 9510678|ERX|0250|AMMONIA AROMATIC AMPULE|Medicare|MEDICARE ACUTE|||||9.50||| 9510678|ERX|0250|AMMONIA AROMATIC AMPULE|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||9.50||| 9510710|ERX|0250|CARBOPROST 250MCG/ML|Managed Medicaid|MEDICAID SUPERIOR|869.25||||||| 9510710|ERX|0250|CARBOPROST 250MCG/ML|Medicaid|MEDICAID|869.25||||||| 9510710|ERX|0250|CARBOPROST 250MCG/ML|Managed Medicaid|MEDICAID AMERIGROUP|869.25||||||| 9510710|ERX|0250|CARBOPROST 250MCG/ML|United Healthcare|UNITED HEALTHCARE OTHER|869.25||||||| 9510751|ERX|0250|KETAMINE 10MG/ML, 20ML|Aenta Medicare Advantage|AETNA MEDICARE MA|2.08||||2.08||| 9510751|ERX|0250|KETAMINE 10MG/ML, 20ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.08||| 9510751|ERX|0250|KETAMINE 10MG/ML, 20ML|Blue Cross HMO Specialty|BCBSTX HMO|2.08||||2.08||| 9510751|ERX|0250|KETAMINE 10MG/ML, 20ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.08||||2.08||| 9510751|ERX|0250|KETAMINE 10MG/ML, 20ML|Blue Cross PPO Specialty|BCBSTX PPO|2.08||||2.08||| 9510751|ERX|0250|KETAMINE 10MG/ML, 20ML|Humana Medicare Advantage|HUMANA MA|2.08||||2.08||| 9510751|ERX|0250|KETAMINE 10MG/ML, 20ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2.08||| 9510751|ERX|0250|KETAMINE 10MG/ML, 20ML|Managed Medicaid|MEDICAID SUPERIOR|2.08||||2.08||| 9510751|ERX|0250|KETAMINE 10MG/ML, 20ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||2.08||| 9510751|ERX|0250|KETAMINE 10MG/ML, 20ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.08||||2.08||| 9510751|ERX|0250|KETAMINE 10MG/ML, 20ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|2.08||||2.08||| 9510751|ERX|0250|KETAMINE 10MG/ML, 20ML|Blue Cross PPO Specialty|BCBSTX OTHER|||||2.08||| 9510751|ERX|0250|KETAMINE 10MG/ML, 20ML|Managed Medicaid|MEDICAID AMERIGROUP|2.08||||2.08||| 9510751|ERX|0250|KETAMINE 10MG/ML, 20ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.08||||2.08||| 9510751|ERX|0250|KETAMINE 10MG/ML, 20ML|Aetna|AETNA PPO|||||2.08||| 9510751|ERX|0250|KETAMINE 10MG/ML, 20ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.08||||2.08||| 9510751|ERX|0250|KETAMINE 10MG/ML, 20ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||2.08||| 9510751|ERX|0250|KETAMINE 10MG/ML, 20ML|Veterans Affairs|VETERANS ADMINISTRATION|2.08||||2.08||| 9510751|ERX|0250|KETAMINE 10MG/ML, 20ML|United Healthcare|UMR UNITED MEDICAL RESOURCES|2.08||||||| 9510751|ERX|0250|KETAMINE 10MG/ML, 20ML|Workers Compensation|WORKERS COMPENSATION OTHER|||||2.08||| 9510751|ERX|0250|KETAMINE 10MG/ML, 20ML|NON CONTRACTED|COMMERCIAL OTHER 1|2.08||||2.08||| 9510751|ERX|0250|KETAMINE 10MG/ML, 20ML|United Healthcare|UNITED HEALTHCARE|||||2.08||| 9510751|ERX|0250|KETAMINE 10MG/ML, 20ML|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|2.08||||||| 9510751|ERX|0250|KETAMINE 10MG/ML, 20ML|Managed Medicare|HEALTHSPRING MA|||||2.08||| 9510751|ERX|0250|KETAMINE 10MG/ML, 20ML|Medicare|MEDICARE ACUTE|2.08||||2.08||| 9510751|ERX|0250|KETAMINE 10MG/ML, 20ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||2.08||| 9510751|ERX|0250|KETAMINE 10MG/ML, 20ML|Medicaid|MEDICAID|2.08||||2.08||| 9510751|ERX|0250|KETAMINE 10MG/ML, 20ML|Medicare|MEDICARE PART B ONLY IP|||||2.08||| 9510777|ERX|0250|CALCITRIOL 0.25MCG CAPSUL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|17.50||||||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|Medicaid|MEDICAID|41.50||||||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|41.50||||||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|Medicare|MEDICARE ACUTE|41.50||||||| 9510850|ERX|0250|HYDROCORTISONE 100MG/2ML|Blue Cross PPO Specialty|BCBSTX PPO|41.50||||||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.13||||0.13||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.13||||0.13||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|United Healthcare|UMR UNITED MEDICAL RESOURCES|0.13||||||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|United Healthcare|UNITED HEALTHCARE|||||0.13||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Managed Medicaid|MEDICAID SUPERIOR|||||0.13||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.13||||0.13||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Aenta Medicare Advantage|AETNA MEDICARE MA|0.13||||||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.13||||0.13||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.13||||||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Blue Cross PPO Specialty|BCBSTX PPO|||||0.13||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|NON CONTRACTED|COMMERCIAL OTHER 1|0.13||||||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Medicaid|MEDICAID|||||0.13||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Medicare|MEDICARE ACUTE|0.13||||0.13||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Humana Medicare Advantage|HUMANA MA|0.13||||0.13||| 9510918|ERX|0250|MAGNESIUM CITRATE 300ML|Rusk State Hospital|RUSK STATE HOSP|0.13||||||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Blue Cross PPO Specialty|BCBSTX PPO|||||7.25||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Managed Medicaid|MEDICAID SUPERIOR|||||7.25||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||7.25||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Humana Medicare Advantage|HUMANA MA|||||7.25||| 9510926|ERX|0250|ALBUTEROL 0.083% SOLN 2.5|Managed Medicaid|MEDICAID AMERIGROUP|7.25||||||| 9511015|ERX|0250|SILVER SULFADIAZINE 1% 5|Medicaid|MEDICAID|||||86.75||| 9511015|ERX|0250|SILVER SULFADIAZINE 1% 5|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||86.75||| 9511015|ERX|0250|SILVER SULFADIAZINE 1% 5|Managed Medicaid|MEDICAID SUPERIOR|||||86.75||| 9511015|ERX|0250|SILVER SULFADIAZINE 1% 5|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||86.75||| 9511015|ERX|0250|SILVER SULFADIAZINE 1% 5|Managed Medicaid|MEDICAID AMERIGROUP|||||86.75||| 9511015|ERX|0250|SILVER SULFADIAZINE 1% 5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||86.75||| 9511015|ERX|0250|SILVER SULFADIAZINE 1% 5|Blue Cross PPO Specialty|BCBSTX PPO|||||86.75||| 9511080|ERX|0250|HYDROXYZINE HCL 10MG TABL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.09||||||| 9511080|ERX|0250|HYDROXYZINE HCL 10MG TABL|Managed Medicaid|MEDICAID AMERIGROUP|||||0.09||| 9511080|ERX|0250|HYDROXYZINE HCL 10MG TABL|Medicare|MEDICARE ACUTE|0.09||||||| 9511239|ERX|0250|GLYCERIN-WITCH HAZEL PADS|Managed Medicaid|MEDICAID SUPERIOR|0.32||||||| 9511239|ERX|0250|GLYCERIN-WITCH HAZEL PADS|Tricare|TRICARE EAST REGION|0.32||||||| 9511239|ERX|0250|GLYCERIN-WITCH HAZEL PADS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.32||||||| 9511239|ERX|0250|GLYCERIN-WITCH HAZEL PADS|Medicaid|MEDICAID|0.32||||||| 9511239|ERX|0250|GLYCERIN-WITCH HAZEL PADS|Managed Medicaid|MEDICAID AMERIGROUP|0.32||||||| 9511239|ERX|0250|GLYCERIN-WITCH HAZEL PADS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.32||||||| 9511239|ERX|0250|GLYCERIN-WITCH HAZEL PADS|United Healthcare|UNITED HEALTHCARE|0.32||||||| 9511239|ERX|0250|GLYCERIN-WITCH HAZEL PADS|Blue Cross HMO Specialty|BCBSTX HMO|0.32||||||| 9511239|ERX|0250|GLYCERIN-WITCH HAZEL PADS|Blue Cross PPO Specialty|BCBSTX PPO|0.32||||||| 9511262|ERX|0250|SOTALOL 80MG TABLET|Humana Medicare Advantage|HUMANA MA|||||34.50||| 9511262|ERX|0250|SOTALOL 80MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|34.50||||||| 9511262|ERX|0250|SOTALOL 80MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|34.50||||||| 9511262|ERX|0250|SOTALOL 80MG TABLET|Medicare|MEDICARE ACUTE|34.50||||||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Medicare|MEDICARE ACUTE|||||101.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||101.75||| 9511270|ERX|0250|METHYLPREDNISOL DEPO 40MG|United Medicare Advantage|UHC MEDICARE GOLD MA|||||101.75||| 9511361|ERX|0250|FENTANYL 25MCG PATCH|Medicare|MEDICARE ACUTE|192.50||||||| 9511379|ERX|0250|FENTANYL 50MCG PATCH|Medicare|MEDICARE ACUTE|351.75||||||| 9511379|ERX|0250|FENTANYL 50MCG PATCH|Workers Compensation|WORKERS COMPENSATION OTHER|351.75||||||| 9511387|ERX|0250|FENTANYL 75MCG PATCH|United Healthcare|UMR UNITED MEDICAL RESOURCES|5.36||||||| 9511445|ERX|0250|RISPERIDONE 1MG TABLET|Rusk State Hospital|RUSK STATE HOSP|49.75||||||| 9511445|ERX|0250|RISPERIDONE 1MG TABLET|Medicare|MEDICARE ACUTE|49.75||||||| 9511445|ERX|0250|RISPERIDONE 1MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|49.75||||||| 9511445|ERX|0250|RISPERIDONE 1MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|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|Blue Cross PPO Specialty|BCBSTX PPO|174.25||||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|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||174.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Managed Medicaid|MEDICAID AMERIGROUP|||||174.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Brinson Benefits|THE HEALTH PLAN SMITH CO|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 CIGNA HEALTHSPRING|||||174.25||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Aenta Medicare Advantage|AETNA MEDICARE MA|174.25||||||| 9511452|ERX|0250|CLINDAMYCIN 600MG/50ML D5|Medicare|MEDICARE ACUTE|174.25||||174.25||| 95115|EAP|0761|IMMUNOTHERAPY ONE INJECTI|Managed Medicaid|MEDICAID AMERIGROUP|||||1.50||| 95115|EAP|0761|IMMUNOTHERAPY ONE INJECTI|Medicaid|MEDICAID|||||1.50||| 95115|EAP|0761|IMMUNOTHERAPY ONE INJECTI|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.50||| 95115|EAP|0250|ALLERGY INJECTION|Managed Medicaid|MEDICAID SUPERIOR|||||107.50||| 95115|EAP|0761|IMMUNOTHERAPY ONE INJECTI|Blue Cross HMO Specialty|BCBSTX HMO|||||1.50||| 9511551|ERX|0250|CLINDAMYCIN 300MG/50ML D5|United Healthcare|UNITED HEALTHCARE|||||127.50||| 9511551|ERX|0250|CLINDAMYCIN 300MG/50ML D5|Medicare|MEDICARE ACUTE|127.50||||||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Rusk State Hospital|RUSK STATE HOSP|||||370.50||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Medicare|MEDICARE ACUTE|370.50||||370.50||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|370.50||||370.50||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Aenta Medicare Advantage|AETNA MEDICARE MA|370.50||||||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Medicaid|MEDICAID HMO|||||370.50||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Blue Cross HMO Specialty|BCBSTX HMO|370.50||||||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||370.50||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|370.50||||||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Blue Cross PPO Specialty|BCBSTX PPO|370.50||||370.50||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Humana Medicare Advantage|HUMANA MA|370.50||||||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Managed Medicaid|MEDICAID AMERIGROUP|||||370.50||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Managed Medicaid|MEDICAID SUPERIOR|370.50||||370.50||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|370.50||||370.50||| 9511650|ERX|0250|LEVETIRACETAM 500MG/5ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||370.50||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Managed Medicaid|MEDICAID AMERIGROUP|1.98||||1.98||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Humana Medicare Advantage|HUMANA MA|1.98||||||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Managed Medicaid|MEDICAID SUPERIOR|1.98||||1.98||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1.98||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|United Medicare Advantage|AARP UHC WEST COMPLETE MA|1.98||||||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1.98||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Aenta Medicare Advantage|AETNA MEDICARE MA|1.98||||||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.98||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Aetna|AETNA PPO|1.98||||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|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.98||||1.98||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Blue Cross HMO Specialty|BCBSTX HMO|||||1.98||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|NON CONTRACTED|COMMERCIAL OTHER 1|1.98||||||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Medicare|MEDICARE ACUTE|||||1.98||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1.98||||||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Managed Medicare|HEALTHSPRING MA|1.98||||||| 9511668|ERX|0250|CLINDAMYCIN 900MG/50ML D5|Medicaid|MEDICAID|1.98||||||| 95117|EAP|0940|IMMUNOTHERAPY INJECTIONS|Blue Cross HMO Specialty|BCBSTX HMO|||||1.50||| 95117|EAP|0940|IMMUNOTHERAPY INJECTIONS|Managed Medicaid|MEDICAID SUPERIOR|||||1.50||| 95117|EAP|0940|IMMUNOTHERAPY INJECTIONS|Managed Medicaid|MEDICAID AMERIGROUP|||||1.50||| 95117|EAP|0940|IMMUNOTHERAPY INJECTIONS|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.50||| 95117|EAP|0940|IMMUNOTHERAPY INJECTIONS|United Healthcare|UNITED HEALTHCARE OTHER|||||1.50||| 95117|EAP|0940|IMMUNOTHERAPY INJECTIONS|United Healthcare|UNITED HEALTHCARE|||||1.50||| 95117|EAP|0940|IMMUNOTHERAPY INJECTIONS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1.50||| 95117|EAP|0940|IMMUNOTHERAPY INJECTIONS|Humana Medicare Advantage|HUMANA MA|||||1.50||| 95117|EAP|0940|IMMUNOTHERAPY INJECTIONS|Blue Cross PPO Specialty|BCBSTX PPO|||||1.50||| 95117|EAP|0940|IMMUNOTHERAPY INJECTIONS|Cigna|CIGNA|||||1.50||| 95117|EAP|0940|IMMUNOTHERAPY INJECTIONS|Medicare|MEDICARE ACUTE|||||1.50||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Veterans Affairs|VETERANS ADMINISTRATION|||||36.75||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|36.75||||||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Humana Medicare Advantage|HUMANA MA|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|Aenta Medicare Advantage|AETNA MEDICARE MA|36.75||||||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Blue Cross HMO Specialty|BCBSTX HMO|||||36.75||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|36.75||||||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Medicaid|MEDICAID|||||36.75||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|Medicare|MEDICARE ACUTE|36.75||||36.75||| 9511700|ERX|0250|LEVETIRACETAM 500MG TABLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|36.75||||36.75||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Medicaid|MEDICAID|0.09||||0.09||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.09||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Medicaid|MEDICAID HMO|||||0.09||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|NON CONTRACTED|COMMERCIAL OTHER 1|0.09||||0.09||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Medicare|MEDICARE ACUTE|0.09||||0.09||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Aenta Medicare Advantage|AETNA MEDICARE MA|0.09||||0.09||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.09||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|0.09||||0.09||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Managed Medicare|HEALTHSPRING MA|0.09||||||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Blue Cross HMO Specialty|BCBSTX HMO|0.09||||0.09||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Aetna|AETNA PPO|0.09||||0.09||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.09||||0.09||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Blue Cross PPO Specialty|BCBSTX OTHER|0.09||||||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Managed Medicaid|MEDICAID AMERIGROUP|0.09||||0.09||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Aetna|AETNA OTHER|||||0.09||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.09||||||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Medicaid|MEDICAID TEXAS CHILDRENS|||||0.09||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Cigna|CIGNA|0.09||||0.09||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.09||||0.09||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Rusk State Hospital|RUSK STATE HOSP|0.09||||0.09||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Brinson Benefits|THE HEALTH PLAN SMITH CO|0.09||||||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.09||||0.09||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Humana Medicare Advantage|HUMANA MA|0.09||||0.09||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|United Healthcare|UNITED HEALTHCARE|0.09||||0.09||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||0.09||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.09||||0.09||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|United Healthcare|TML GROUP BENEFITS|0.09||||||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Managed Medicaid|MEDICAID SUPERIOR|0.09||||0.09||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|0.09||||0.09||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.09||||0.09||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|United Healthcare|UNITED HEALTHCARE OTHER|||||0.09||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.09||||0.09||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Workers Compensation|WORKERS COMPENSATION OTHER|0.09||||0.09||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Workers Compensation|UT EMPLOYEE INJURY|0.09||||0.09||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|0.09||||0.09||| 9511809|ERX|0250|ACETAMINOPHEN 500MG TABLE|Veterans Affairs|VETERANS ADMINISTRATION|0.09||||0.09||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||1.63||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|United Healthcare|UNITED HEALTHCARE OTHER|||||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|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1.63||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Workers Compensation|UT EMPLOYEE INJURY|||||1.63||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|United Healthcare|UNITED HEALTHCARE|||||1.63||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Cigna|CIGNA|||||1.63||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1.63||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Humana Medicare Advantage|HUMANA MA|||||1.63||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Veterans Affairs|VETERANS ADMINISTRATION|||||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||||1.63||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||1.63||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1.63||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Aenta Medicare Advantage|AETNA MEDICARE MA|||||1.63||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1.63||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Blue Cross HMO Specialty|BCBSTX HMO|||||1.63||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Blue Cross PPO Specialty|BCBSTX OTHER|||||1.63||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Managed Medicaid|MEDICAID AMERIGROUP|||||1.63||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Tricare|TRICARE EAST REGION|||||1.63||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.63||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.63||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||1.63||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||1.63||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Medicaid|MEDICAID|||||1.63||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Workers Compensation|WORKERS COMPENSATION OTHER|||||1.63||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Medicare|MEDICARE ACUTE|||||1.63||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.63||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Aetna|AETNA OTHER|||||1.63||| 9511817|ERX|0250|METHYLPREDNISOL DEPO 80MG|Blue Cross PPO Specialty|BCBSTX PPO|||||1.63||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Medicaid|MEDICAID TEXAS CHILDRENS|||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.50||||||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Medicaid|MOLINA HEALTHCARE OF TEXAS|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Aenta Medicare Advantage|AETNA MEDICARE MA|2.50||||||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Rusk State Hospital|RUSK STATE HOSP|2.50||||||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.50||||||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Aetna|AETNA OTHER|2.50||||||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|NON CONTRACTED|COMMERCIAL OTHER 1|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Blue Cross HMO Specialty|BCBSTX HMO|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Managed Medicaid|MEDICAID AMERIGROUP|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Medicaid|MEDICAID|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Cigna|CIGNA|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Managed Medicaid|MEDICAID SUPERIOR|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.50||||||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|United Healthcare|UNITED HEALTHCARE OTHER|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Veterans Affairs|VETERANS ADMINISTRATION|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|Workers Compensation|UT EMPLOYEE INJURY|||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|2.50||||||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|United Healthcare|UNITED HEALTHCARE|||||2.50||| 9511825|ERX|0250|ACETAMINOPHEN 325MG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||2.50||| 9511858|ERX|0250|OMEPRAZOLE 20MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|38.50||||||| 9511858|ERX|0250|OMEPRAZOLE 20MG CAPSULE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|38.50||||38.50||| 9511858|ERX|0250|OMEPRAZOLE 20MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|38.50||||||| 9511858|ERX|0250|OMEPRAZOLE 20MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|38.50||||||| 9511858|ERX|0250|OMEPRAZOLE 20MG CAPSULE|Humana Medicare Advantage|HUMANA MA|38.50||||38.50||| 9511858|ERX|0250|OMEPRAZOLE 20MG CAPSULE|Workers Compensation|WORKERS COMPENSATION OTHER|||||38.50||| 9511858|ERX|0250|OMEPRAZOLE 20MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||38.50||| 9511858|ERX|0250|OMEPRAZOLE 20MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|38.50||||38.50||| 9511858|ERX|0250|OMEPRAZOLE 20MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|38.50||||||| 9511858|ERX|0250|OMEPRAZOLE 20MG CAPSULE|Blue Cross PPO Specialty|BCBSTX OTHER|||||38.50||| 9511858|ERX|0250|OMEPRAZOLE 20MG CAPSULE|Tricare|TRICARE EAST REGION|38.50||||||| 9511858|ERX|0250|OMEPRAZOLE 20MG CAPSULE|Medicare|MEDICARE ACUTE|38.50||||38.50||| 9511858|ERX|0250|OMEPRAZOLE 20MG CAPSULE|UTMB|UTMB CORRECTIONAL MANAGED CARE|38.50||||38.50||| 9511858|ERX|0250|OMEPRAZOLE 20MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|38.50||||||| 9511858|ERX|0250|OMEPRAZOLE 20MG CAPSULE|Managed Medicare|HEALTHSPRING MA|38.50||||||| 9511858|ERX|0250|OMEPRAZOLE 20MG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||38.50||| 9511858|ERX|0250|OMEPRAZOLE 20MG CAPSULE|Rusk State Hospital|RUSK STATE HOSP|38.50||||||| 9511858|ERX|0250|OMEPRAZOLE 20MG CAPSULE|Medicaid|MEDICAID|||||38.50||| 9511858|ERX|0250|OMEPRAZOLE 20MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|38.50||||||| 9511874|ERX|0250|CEFUROXIME 250MG TABLET|Humana Medicare Advantage|HUMANA MA|43.25||||||| 9511874|ERX|0250|CEFUROXIME 250MG TABLET|Medicare|MEDICARE ACUTE|43.25||||||| 9511874|ERX|0250|CEFUROXIME 250MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|||||43.25||| 9511874|ERX|0250|CEFUROXIME 250MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|43.25||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|United Healthcare|UNITED HEALTHCARE OTHER|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|United Healthcare|UNITED HEALTHCARE|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Aenta Medicare Advantage|AETNA MEDICARE MA|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Cigna|CIGNA|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Aetna|AETNA PPO|3.75||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Blue Cross HMO Specialty|BCBSTX HMO|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|Humana Medicare Advantage|HUMANA MA|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Workers Compensation|WORKERS COMPENSATION 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|Managed Medicaid|MEDICAID SUPERIOR|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Managed Medicaid|MEDICAID AMERIGROUP|2.50||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Medicaid|MEDICAID|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Medicaid|MOLINA HEALTHCARE OF TEXAS|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||2.50||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Tricare|TRICARE EAST REGION|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|NON CONTRACTED|COMMERCIAL OTHER 1|2.50||||||| 9511890|ERX|0250|DOCUSATE SODIUM 100MG CAP|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9511908|ERX|0250|TORSEMIDE 10MG TABLET|Medicare|MEDICARE ACUTE|11.50||||||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Humana Medicare Advantage|HUMANA MA|0.03||||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 TPA UTH UMR|0.03||||||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|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|Managed Medicare|HEALTHSPRING MA|0.03||||||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Medicaid|MEDICAID|0.03||||||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.03||||||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|0.03||||||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Tricare|TRICARE EAST REGION|0.03||||||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Medicare|MEDICARE ACUTE|0.03||||0.03||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.03||||||| 9511932|ERX|0250|FOLIC ACID 1MG TABLET|Rusk State Hospital|RUSK STATE HOSP|0.03||||||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.09||||||| 9511940|ERX|0250|CARISOPRODOL 350MG TABLET|Medicare|MEDICARE ACUTE|0.09||||||| 9511957|ERX|0250|CHLORTHALIDONE 25MG TABLE|Aenta Medicare Advantage|AETNA MEDICARE MA|0.04||||||| 9511957|ERX|0250|CHLORTHALIDONE 25MG TABLE|Humana Medicare Advantage|HUMANA MA|0.04||||||| 9511957|ERX|0250|CHLORTHALIDONE 25MG TABLE|Tricare|TRICARE EAST REGION|0.04||||||| 9511957|ERX|0250|CHLORTHALIDONE 25MG TABLE|Medicare|MEDICARE ACUTE|0.04||||||| 9511999|ERX|0250|DIPHENOX-ATROP 2.5-0.025M|Medicaid|MEDICAID|||||8.25||| 9511999|ERX|0250|DIPHENOX-ATROP 2.5-0.025M|Medicaid|MEDICAID TEXAS CHILDRENS|||||8.25||| 9511999|ERX|0250|DIPHENOX-ATROP 2.5-0.025M|Tricare|TRICARE EAST REGION|||||8.25||| 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|NON CONTRACTED|COMMERCIAL OTHER 1|8.25||||||| 9511999|ERX|0250|DIPHENOX-ATROP 2.5-0.025M|United Healthcare|UNITED HEALTHCARE|||||8.25||| 9511999|ERX|0250|DIPHENOX-ATROP 2.5-0.025M|United Medicare Advantage|UHC MEDICARE GOLD MA|||||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|Medicaid|MEDICAID PCCM|||||8.25||| 9511999|ERX|0250|DIPHENOX-ATROP 2.5-0.025M|Cigna|CIGNA|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|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||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 CIGNA HEALTHSPRING|||||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|Blue Cross PPO Specialty|BCBSTX PPO|||||8.25||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Managed Medicaid|MEDICAID SUPERIOR|2.50||||||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|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|Workers Compensation|WORKERS COMPENSATION OTHER|2.50||||||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|NON CONTRACTED|COMMERCIAL OTHER 1|2.50||||||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Medicare|MEDICARE ACUTE|2.50||||||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Aenta Medicare Advantage|AETNA MEDICARE MA|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|Blue Cross PPO Specialty|BCBSTX PPO|2.50||||||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Cigna|CIGNA|2.50||||||| 9512021|ERX|0250|DOCUSATE CALCIUM 240MG CA|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.50||||||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Medicaid|MEDICAID|2.75||||||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|2.75||||||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Medicare|MEDICARE ACUTE|2.75||||2.75||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|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||||||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.75||||||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Humana Medicare Advantage|HUMANA MA|2.75||||2.75||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|2.75||||||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.75||||||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|2.75||||||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.75||||||| 9512039|ERX|0250|FUROSEMIDE 20MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|2.75||||||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.03||||||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.03||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.03||||0.03||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.03||||||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Humana Medicare Advantage|HUMANA MA|0.03||||0.03||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.03||||||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.03||||0.03||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.03||||||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.03||||||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.03||||||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|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|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.03||||||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Rusk State Hospital|RUSK STATE HOSP|0.03||||||| 9512047|ERX|0250|FUROSEMIDE 40MG TABLET|Medicaid|MEDICAID|0.03||||||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.27||||||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|Medicare|MEDICARE ACUTE|0.27||||0.27||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.27||||0.27||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|Humana Medicare Advantage|HUMANA MA|0.27||||||| 9512070|ERX|0250|MIRTAZAPINE 15MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.27||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|||||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||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|Humana Medicare Advantage|HUMANA MA|0.05||||0.05||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|Cigna|CIGNA|||||0.05||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.05||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.05||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.05||||0.05||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|||||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|United Healthcare|UNITED HEALTHCARE|||||0.05||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|Medicaid|MEDICAID|0.05||||||| 9512104|ERX|0250|MECLIZINE 25MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|||||0.05||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|Managed Medicare|HEALTHSPRING MA|7.50||||||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|Rusk State Hospital|RUSK STATE HOSP|7.50||||||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|Medicare|MEDICARE ACUTE|7.50||||7.50||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|United Healthcare|UNITED HEALTHCARE|7.50||||||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.50||||||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|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||||||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.50||||||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|7.50||||||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|7.50||||||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|Aenta Medicare Advantage|AETNA MEDICARE MA|7.50||||||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.50||||||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|Blue Cross HMO Specialty|BCBSTX HMO|||||7.50||| 9512112|ERX|0250|SPIRONOLACTONE 25MG TABLE|NON CONTRACTED|COMMERCIAL OTHER 1|7.50||||||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|6.75||||||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|Humana Medicare Advantage|HUMANA MA|6.75||||||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6.75||||6.75||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|6.75||||||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|6.75||||||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|6.75||||||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|6.75||||||| 9512138|ERX|0250|AMITRIPTYLINE 25MG TABLET|Medicare|MEDICARE ACUTE|6.75||||||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|Medicaid|MEDICAID|||||12.50||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|NON CONTRACTED|COMMERCIAL OTHER 1|12.50||||||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|Medicare|MEDICARE ACUTE|12.50||||12.50||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|United Healthcare|UNITED HEALTHCARE|||||12.50||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||12.50||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|Aenta Medicare Advantage|AETNA MEDICARE MA|12.50||||||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|Aetna|AETNA OTHER|||||12.50||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|||||12.50||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|Managed Medicaid|MEDICAID AMERIGROUP|12.50||||||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|Cigna|CIGNA|12.50||||||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|12.50||||12.50||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|Managed Medicaid|MEDICAID SUPERIOR|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 CIGNA HEALTHSPRING|||||12.50||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|Brinson Benefits|THE HEALTH PLAN SMITH CO|12.50||||||| 9512161|ERX|0250|METRONIDAZOLE 500MG TABLE|Humana Medicare Advantage|HUMANA MA|12.50||||12.50||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Humana Medicare Advantage|HUMANA MA|18.25||||||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Managed Medicaid|MEDICAID AMERIGROUP|18.25||||18.25||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Managed Medicaid|MEDICAID SUPERIOR|18.25||||||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||18.25||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|18.25||||18.25||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Aenta Medicare Advantage|AETNA MEDICARE MA|18.25||||||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Blue Cross HMO Specialty|BCBSTX HMO|||||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|Blue Cross PPO Specialty|BCBSTX PPO|18.25||||18.25||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|United Healthcare|UNITED HEALTHCARE|||||18.25||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||18.25||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||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|NON CONTRACTED|COMMERCIAL OTHER 1|18.25||||||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Medicare|MEDICARE ACUTE|18.25||||18.25||| 9512179|ERX|0250|SULFAMETH-TRIMETH 800-160|Medicaid|MEDICAID|18.25||||18.25||| 9512195|ERX|0250|AMITRIPTYLINE 10MG TABLET|Medicare|MEDICARE ACUTE|0.04||||||| 9512203|ERX|0250|LORATADINE 10MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|12.75||||||| 9512203|ERX|0250|LORATADINE 10MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12.75||||||| 9512203|ERX|0250|LORATADINE 10MG TABLET|Cigna|CIGNA|12.75||||||| 9512203|ERX|0250|LORATADINE 10MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|12.75||||||| 9512203|ERX|0250|LORATADINE 10MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|12.75||||||| 9512203|ERX|0250|LORATADINE 10MG TABLET|Humana Medicare Advantage|HUMANA MA|12.75||||||| 9512203|ERX|0250|LORATADINE 10MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|12.75||||||| 9512203|ERX|0250|LORATADINE 10MG TABLET|Rusk State Hospital|RUSK STATE HOSP|12.75||||||| 9512203|ERX|0250|LORATADINE 10MG TABLET|Medicare|MEDICARE ACUTE|12.75||||||| 9512203|ERX|0250|LORATADINE 10MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|12.75||||||| 9512229|ERX|0250|CHLORDIAZEPOXIDE 25MG CAP|Medicaid|MEDICAID|4.75||||||| 9512229|ERX|0250|CHLORDIAZEPOXIDE 25MG CAP|Medicare|MEDICARE ACUTE|4.75||||||| 9512229|ERX|0250|CHLORDIAZEPOXIDE 25MG CAP|United Medicare Advantage|AARP UHC WEST COMPLETE MA|4.75||||||| 9512229|ERX|0250|CHLORDIAZEPOXIDE 25MG CAP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4.75||||||| 9512229|ERX|0250|CHLORDIAZEPOXIDE 25MG CAP|Humana Medicare Advantage|HUMANA MA|4.75||||||| 9512229|ERX|0250|CHLORDIAZEPOXIDE 25MG CAP|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.75||||||| 9512229|ERX|0250|CHLORDIAZEPOXIDE 25MG CAP|Blue Cross PPO Specialty|BCBSTX PPO|4.75||||||| 9512229|ERX|0250|CHLORDIAZEPOXIDE 25MG CAP|United Medicare Advantage|UHC MEDICARE GOLD MA|4.75||||||| 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|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.06||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Aenta Medicare Advantage|AETNA MEDICARE MA|||||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|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.06||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Cigna|CIGNA|||||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 CIGNA HEALTHSPRING|||||0.06||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Managed Medicaid|MEDICAID SUPERIOR|||||0.06||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Managed Medicaid|MEDICAID AMERIGROUP|||||0.06||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|United Healthcare|UNITED HEALTHCARE|||||0.06||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.06||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Veterans Affairs|VETERANS ADMINISTRATION|0.06||||||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.06||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Tricare|TRICARE EAST REGION|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|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||0.06||| 9512245|ERX|0250|ACETAM-CODEINE 300-30MG T|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.06||||||| 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 ACUTE|4.75||||4.75||| 9512336|ERX|0250|ALLOPURINOL 100MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|4.75||||||| 9512336|ERX|0250|ALLOPURINOL 100MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|4.75||||||| 9512336|ERX|0250|ALLOPURINOL 100MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|4.75||||||| 9512336|ERX|0250|ALLOPURINOL 100MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4.75||||4.75||| 9512336|ERX|0250|ALLOPURINOL 100MG TABLET|Humana Medicare Advantage|HUMANA MA|4.75||||4.75||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|Medicare|MEDICARE ACUTE|||||0.09||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.09||||||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|Cigna|CIGNA|0.09||||||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|Humana Medicare Advantage|HUMANA MA|0.09||||||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.09||||||| 9512344|ERX|0250|ALLOPURINOL 300MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.09||||||| 9512351|ERX|0250|BENZTROPINE 1MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||5.25||| 9512351|ERX|0250|BENZTROPINE 1MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||5.25||| 9512351|ERX|0250|BENZTROPINE 1MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.25||||||| 9512351|ERX|0250|BENZTROPINE 1MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|5.25||||||| 9512351|ERX|0250|BENZTROPINE 1MG TABLET|Rusk State Hospital|RUSK STATE HOSP|5.25||||||| 9512351|ERX|0250|BENZTROPINE 1MG TABLET|Medicare|MEDICARE ACUTE|5.25||||||| 9512351|ERX|0250|BENZTROPINE 1MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|5.25||||||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|Medicaid|MEDICAID|4.50||||||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||4.50||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|||||4.50||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.50||||||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|4.50||||||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||4.50||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|4.50||||4.50||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|||||4.50||| 9512377|ERX|0250|IBUPROFEN 400MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||4.50||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|United Healthcare|UNITED HEALTHCARE|||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|5.25||||||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|5.25||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||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||||||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Humana Medicare Advantage|HUMANA MA|||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.25||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|5.25||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Rusk State Hospital|RUSK STATE HOSP|5.25||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Medicare|MEDICARE ACUTE|5.25||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|||||5.25||| 9512385|ERX|0250|IBUPROFEN 600MG TABLET|Medicaid|MEDICAID PCCM|||||5.25||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|Medicaid|MEDICAID|0.05||||0.05||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|Medicare|MEDICARE ACUTE|0.05||||||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|Managed Medicaid|MEDICAID SUPERIOR|||||0.05||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.05||||||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|United Healthcare|UMR UNITED MEDICAL RESOURCES|0.05||||||| 9512393|ERX|0250|METOCLOPRAMIDE 10MG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.05||||||| 9512401|ERX|0250|TOLTERODINE 1MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|24.50||||||| 9512401|ERX|0250|TOLTERODINE 1MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|24.50||||||| 9512419|ERX|0250|DIAZEPAM 2MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.05||||||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Medicare|MEDICARE ACUTE|5.50||||5.50||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||5.50||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Managed Medicare|HEALTHSPRING MA|5.50||||||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Humana Medicare Advantage|HUMANA MA|5.50||||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||||||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|5.50||||||| 9512427|ERX|0250|DIAZEPAM 5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||5.50||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.05||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||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 OTHER|||||0.05||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Aetna|AETNA PPO|||||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|Managed Medicaid|MEDICAID AMERIGROUP|||||0.05||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||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|Managed Medicaid|MEDICAID SUPERIOR|0.05||||||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.05||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||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 Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.05||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Managed Medicare|HEALTHSPRING MA|0.05||||||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Medicaid|MEDICAID|0.05||||0.05||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.05||| 9512443|ERX|0250|CLONIDINE 0.1MG TABLET|Medicare|MEDICARE ACUTE|0.05||||0.05||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|||||5.50||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Rusk State Hospital|RUSK STATE HOSP|||||5.50||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Medicare|MEDICARE ACUTE|5.50||||5.50||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Medicaid|MEDICAID|5.50||||5.50||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||5.50||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||5.50||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||5.50||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||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 SUPERIOR|||||5.50||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|5.50||||5.50||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|||||5.50||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||5.50||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||5.50||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|United Healthcare|UNITED HEALTHCARE|||||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|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.50||||5.50||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|5.50||||5.50||| 9512450|ERX|0250|CLONIDINE 0.2MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|||||5.50||| 9512484|ERX|0250|CHLORDIAZEPOXIDE 5MG CAPS|United Medicare Advantage|UHC MEDICARE GOLD MA|4.25||||||| 9512484|ERX|0250|CHLORDIAZEPOXIDE 5MG CAPS|Blue Cross PPO Specialty|BCBSTX PPO|4.25||||||| 9512484|ERX|0250|CHLORDIAZEPOXIDE 5MG CAPS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.25||||||| 9512484|ERX|0250|CHLORDIAZEPOXIDE 5MG CAPS|Medicaid|MEDICAID|4.25||||||| 9512484|ERX|0250|CHLORDIAZEPOXIDE 5MG CAPS|Medicare|MEDICARE ACUTE|4.25||||||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|13.50||||||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Medicaid Out of State|MEDICAID LOUISIANA|||||13.50||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Medicare|MEDICARE PART B ONLY IP|13.50||||||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Medicare|MEDICARE ACUTE|13.50||||13.50||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||13.50||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Medicaid|MEDICAID HMO|||||13.50||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|||||13.50||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|||||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 CIGNA HEALTHSPRING|13.50||||13.50||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|||||13.50||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Rusk State Hospital|RUSK STATE HOSP|13.50||||||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|||||13.50||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Aetna|AETNA OTHER|13.50||||||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Medicaid|MEDICAID|13.50||||13.50||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|13.50||||||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|13.50||||13.50||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|13.50||||13.50||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||13.50||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|United Healthcare|UMR UNITED MEDICAL RESOURCES|13.50||||13.50||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|13.50||||13.50||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|United Healthcare|UNITED HEALTHCARE|||||13.50||| 9512518|ERX|0250|LORAZEPAM 1MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|13.50||||||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE 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|Blue Cross HMO Specialty|BCBSTX HMO|0.11||||||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.11||||||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|Humana Medicare Advantage|HUMANA MA|0.11||||||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.11||||||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|Medicare|MEDICARE ACUTE|0.11||||||| 9512534|ERX|0250|LORAZEPAM 0.5MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.11||||||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.11||||||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|0.11||||||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Rusk State Hospital|RUSK STATE HOSP|0.11||||||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Medicare|MEDICARE ACUTE|0.11||||||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Medicare|MEDICARE PART B ONLY IP|0.11||||||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.11||||||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Cigna|CIGNA|0.11||||||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Humana Medicare Advantage|HUMANA MA|0.11||||0.11||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|0.11||||||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|0.11||||||| 9512542|ERX|0250|TEMAZEPAM 15MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|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 Healthcare|UMR UNITED MEDICAL RESOURCES|0.11||||||| 9512567|ERX|0250|CILOSTAZOL 100MG TABLET|Humana Medicare Advantage|HUMANA MA|||||22.50||| 9512567|ERX|0250|CILOSTAZOL 100MG TABLET|Medicare|MEDICARE ACUTE|22.50||||||| 9512575|ERX|0250|GLIMEPIRIDE 2MG TABLET|Medicare|MEDICARE ACUTE|9.50||||9.50||| 9512575|ERX|0250|GLIMEPIRIDE 2MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|||||9.50||| 9512575|ERX|0250|GLIMEPIRIDE 2MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|9.50||||||| 9512575|ERX|0250|GLIMEPIRIDE 2MG TABLET|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|9.50||||||| 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||||9.50||| 9512575|ERX|0250|GLIMEPIRIDE 2MG TABLET|Humana Medicare Advantage|HUMANA MA|9.50||||9.50||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Humana Medicare Advantage|HUMANA MA|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 UTH UMR|||||7.50||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|7.50||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.50||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|7.50||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|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|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.50||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|7.50||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|7.50||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|United Healthcare|UMR UNITED MEDICAL RESOURCES|7.50||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|7.50||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|7.50||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|7.50||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Rusk State Hospital|RUSK STATE HOSP|7.50||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Medicare|MEDICARE PART B ONLY IP|7.50||||||| 9512591|ERX|0250|TRAZODONE 50MG TABLET|Medicare|MEDICARE ACUTE|7.50||||7.50||| 9512617|ERX|0250|LINEZOLID 600MG TABLET|Rusk State Hospital|RUSK STATE HOSP|8.10||||||| 9512617|ERX|0250|LINEZOLID 600MG TABLET|Medicare|MEDICARE ACUTE|8.10||||||| 9512617|ERX|0250|LINEZOLID 600MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|8.10||||||| 9512617|ERX|0250|LINEZOLID 600MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|8.10||||||| 9512617|ERX|0250|LINEZOLID 600MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|8.10||||||| 9512617|ERX|0250|LINEZOLID 600MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|8.10||||||| 9512617|ERX|0250|LINEZOLID 600MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|8.10||||||| 9512617|ERX|0250|LINEZOLID 600MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8.10||||||| 9512633|ERX|0250|MEGESTROL 40MG TABLET|Medicare|MEDICARE ACUTE|||||0.15||| 9512658|ERX|0250|DOXEPIN 25MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||7.50||| 9512658|ERX|0250|DOXEPIN 25MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.50||||||| 9512658|ERX|0250|DOXEPIN 25MG CAPSULE|Medicare|MEDICARE ACUTE|7.50||||||| 9512674|ERX|0250|SIMVASTATIN 20MG TABLET|Medicaid|MEDICAID|||||12.75||| 9512674|ERX|0250|SIMVASTATIN 20MG TABLET|Medicare|MEDICARE ACUTE|12.75||||12.75||| 9512674|ERX|0250|SIMVASTATIN 20MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|12.75||||12.75||| 9512674|ERX|0250|SIMVASTATIN 20MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|12.75||||||| 9512674|ERX|0250|SIMVASTATIN 20MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|12.75||||||| 9512674|ERX|0250|SIMVASTATIN 20MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||12.75||| 9512674|ERX|0250|SIMVASTATIN 20MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|12.75||||||| 9512674|ERX|0250|SIMVASTATIN 20MG TABLET|Humana Medicare Advantage|HUMANA MA|12.75||||||| 9512682|ERX|0250|SIMVASTATIN 40MG TABLET|Humana Medicare Advantage|HUMANA MA|12.75||||||| 9512682|ERX|0250|SIMVASTATIN 40MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|12.75||||||| 9512682|ERX|0250|SIMVASTATIN 40MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|12.75||||||| 9512682|ERX|0250|SIMVASTATIN 40MG TABLET|Medicare|MEDICARE ACUTE|12.75||||||| 9512690|ERX|0250|AMANTADINE 100MG CAPSULE|Medicare|MEDICARE ACUTE|0.09||||0.09||| 9512690|ERX|0250|AMANTADINE 100MG CAPSULE|Rusk State Hospital|RUSK STATE HOSP|0.09||||||| 9512724|ERX|0250|FLUPHENAZINE 5MG TABLET|Medicare|MEDICARE ACUTE|0.16||||||| 9512724|ERX|0250|FLUPHENAZINE 5MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.16||||0.16||| 9512740|ERX|0250|CHLORPROMAZINE 100MG TABL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.25||||||| 9512740|ERX|0250|CHLORPROMAZINE 100MG TABL|Rusk State Hospital|RUSK STATE HOSP|7.25||||||| 9512740|ERX|0250|CHLORPROMAZINE 100MG TABL|Medicare|MEDICARE ACUTE|7.25||||||| 9512773|ERX|0250|CHLORPROMAZINE 25MG TABLE|Rusk State Hospital|RUSK STATE HOSP|0.05||||||| 9512773|ERX|0250|CHLORPROMAZINE 25MG TABLE|Medicare|MEDICARE ACUTE|0.05||||||| 9512773|ERX|0250|CHLORPROMAZINE 25MG TABLE|Blue Cross HMO Specialty|BCBSTX HMO|||||0.05||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|Workers Compensation|WORKERS COMPENSATION OTHER|||||8.25||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|United Healthcare|UNITED HEALTHCARE OTHER|||||8.25||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|United Healthcare|UNITED HEALTHCARE|||||8.25||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|||||8.25||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|United Healthcare|TML GROUP BENEFITS|||||8.25||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||8.25||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||8.25||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|||||8.25||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||8.25||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|Blue Cross PPO Specialty|BCBSTX OTHER|||||8.25||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||8.25||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|Managed Medicare|HEALTHSPRING MA|||||8.25||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|Medicaid|MEDICAID HMO|||||8.25||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||8.25||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|Medicaid|MEDICAID|||||8.25||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|Tricare|TRICARE EAST REGION|||||8.25||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|Humana Medicare Advantage|HUMANA MA|||||8.25||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|Medicare|MEDICARE ACUTE|||||8.25||| 9513011|ERX|0250|AMOXICILLIN 500MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|||||8.25||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Medicare|MEDICARE ACUTE|21.25||||21.25||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Tricare|TRICARE EAST REGION|||||21.25||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||21.25||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Medicaid|MEDICAID|||||21.25||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|21.25||||||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|||||21.25||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|21.25||||21.25||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|||||21.25||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Humana Medicare Advantage|HUMANA MA|21.25||||21.25||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||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 UNITED HEALTHCARE|21.25||||21.25||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||21.25||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||21.25||| 9513029|ERX|0250|CEPHALEXIN 500MG CAPSULE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|21.25||||||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||14.50||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Workers Compensation|WORKERS COMPENSATION OTHER|||||14.50||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Managed Medicaid|MEDICAID AMERIGROUP|||||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|Humana Medicare Advantage|HUMANA MA|14.50||||14.50||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||14.50||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|14.50||||14.50||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Managed Medicaid|MEDICAID SUPERIOR|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 PPO Specialty|BCBSTX PPO|||||14.50||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||14.50||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Medicaid|MEDICAID|||||14.50||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||14.50||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|Medicare|MEDICARE ACUTE|14.50||||14.50||| 9513060|ERX|0250|CYCLOBENZAPRINE 10MG TABL|NON CONTRACTED|COMMERCIAL OTHER 1|||||14.50||| 9513094|ERX|0250|ALBUTEROL 4MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|||||0.08||| 9513136|ERX|0250|VERAPAMIL 80MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|7.25||||||| 9513136|ERX|0250|VERAPAMIL 80MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.25||||||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Humana Medicare Advantage|HUMANA MA|0.11||||||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|0.11||||0.11||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|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|Workers Compensation|UT EMPLOYEE INJURY|0.11||||||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|United Healthcare|UMR UNITED MEDICAL RESOURCES|0.11||||||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Medicaid|MEDICAID|0.11||||0.11||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|Medicare|MEDICARE ACUTE|0.11||||0.11||| 9513169|ERX|0250|LOPERAMIDE 2MG CAPSULE|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.11||||||| 9513185|ERX|0250|IBUPROFEN 200MG TABLET|Medicare|MEDICARE ACUTE|2.50||||||| 9513185|ERX|0250|IBUPROFEN 200MG TABLET|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||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 SUPERIOR|||||2.50||| 9513185|ERX|0250|IBUPROFEN 200MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|||||2.50||| 9513193|ERX|0250|DILTIAZEM 30MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.75||||7.75||| 9513193|ERX|0250|DILTIAZEM 30MG TABLET|Humana Medicare Advantage|HUMANA MA|7.75||||||| 9513193|ERX|0250|DILTIAZEM 30MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|7.75||||7.75||| 9513193|ERX|0250|DILTIAZEM 30MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|7.75||||||| 9513193|ERX|0250|DILTIAZEM 30MG TABLET|Medicaid|MEDICAID|7.75||||||| 9513193|ERX|0250|DILTIAZEM 30MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|7.75||||||| 9513193|ERX|0250|DILTIAZEM 30MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|7.75||||||| 9513193|ERX|0250|DILTIAZEM 30MG TABLET|Medicare|MEDICARE ACUTE|7.75||||||| 9513243|ERX|0250|CARBIDOPA-LEVODOPA 25-100|Medicare|MEDICARE ACUTE|0.12||||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|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.12||||||| 9513250|ERX|0250|ATENOLOL 25MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.12||||||| 9513250|ERX|0250|ATENOLOL 25MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.12||||||| 9513250|ERX|0250|ATENOLOL 25MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.12||||||| 9513250|ERX|0250|ATENOLOL 25MG TABLET|Humana Medicare Advantage|HUMANA MA|0.12||||0.12||| 9513250|ERX|0250|ATENOLOL 25MG TABLET|Medicare|MEDICARE ACUTE|0.12||||||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|11.75||||||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|Medicaid|MEDICAID|11.75||||||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|11.75||||||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|Medicare|MEDICARE ACUTE|11.75||||11.75||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|Cigna|CIGNA|11.75||||||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|Humana Medicare Advantage|HUMANA MA|11.75||||11.75||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|||||11.75||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|11.75||||11.75||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|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||||||| 9513276|ERX|0250|ALPRAZOLAM 0.5MG TABLET|United Healthcare|UMR UNITED MEDICAL RESOURCES|11.75||||||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||16.50||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|Workers Compensation|UT EMPLOYEE INJURY|||||16.50||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||16.50||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|||||16.50||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|||||16.50||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||16.50||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|16.50||||16.50||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|||||16.50||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|Rusk State Hospital|RUSK STATE HOSP|||||16.50||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|Medicare|MEDICARE ACUTE|||||16.50||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|Medicaid|MEDICAID HMO|||||16.50||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|Medicaid|MEDICAID|||||16.50||| 9513292|ERX|0250|NAPROXEN 500MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|||||16.50||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|NON CONTRACTED|COMMERCIAL OTHER 1|0.09||||||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Managed Medicaid|MEDICAID SUPERIOR|0.09||||||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Humana Medicare Advantage|HUMANA MA|0.09||||0.09||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Aenta Medicare Advantage|AETNA MEDICARE MA|0.09||||||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.09||||||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Aetna|AETNA OTHER|0.09||||||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Medicare|MEDICARE ACUTE|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|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.09||||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|Managed Medicare|HEALTHSPRING MA|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|AARP UHC WEST COMPLETE MA|0.09||||0.09||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|Veterans Affairs|VETERANS ADMINISTRATION|0.09||||||| 9513300|ERX|0250|METOPROLOL TARTRATE 50MG|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.09||||0.09||| 9513367|ERX|0250|GLIPIZIDE 5MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|6.75||||||| 9513367|ERX|0250|GLIPIZIDE 5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|6.75||||||| 9513367|ERX|0250|GLIPIZIDE 5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6.75||||||| 9513367|ERX|0250|GLIPIZIDE 5MG TABLET|Medicare|MEDICARE ACUTE|||||6.75||| 9513367|ERX|0250|GLIPIZIDE 5MG TABLET|Medicaid|MEDICAID|||||6.75||| 9513433|ERX|0250|SUCRALFATE 1 G TABLET|Medicare|MEDICARE ACUTE|11.75||||11.75||| 9513433|ERX|0250|SUCRALFATE 1 G TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|11.75||||||| 9513433|ERX|0250|SUCRALFATE 1 G TABLET|Humana Medicare Advantage|HUMANA MA|11.75||||||| 9513433|ERX|0250|SUCRALFATE 1 G TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|11.75||||||| 9513433|ERX|0250|SUCRALFATE 1 G TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|11.75||||||| 9513466|ERX|0250|RANITIDINE 150MG TABLET|Humana Medicare Advantage|HUMANA MA|19.75||||19.75||| 9513466|ERX|0250|RANITIDINE 150MG TABLET|Rusk State Hospital|RUSK STATE HOSP|19.75||||||| 9513466|ERX|0250|RANITIDINE 150MG TABLET|Medicare|MEDICARE ACUTE|19.75||||||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|Managed Medicare|HEALTHSPRING MA|7.25||||||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|7.25||||||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|Medicare|MEDICARE ACUTE|7.25||||||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|7.25||||||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|7.25||||||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.25||||||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|7.25||||||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|7.25||||||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.25||||||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|Humana Medicare Advantage|HUMANA MA|7.25||||||| 9513474|ERX|0250|BUMETANIDE 1MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|7.25||||||| 9513540|ERX|0250|DILTIAZEM SR 120MG CAPSUL|Medicare|MEDICARE ACUTE|0.15||||||| 9513557|ERX|0250|LABETALOL 100MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|8.25||||8.25||| 9513557|ERX|0250|LABETALOL 100MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|8.25||||8.25||| 9513557|ERX|0250|LABETALOL 100MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|||||8.25||| 9513557|ERX|0250|LABETALOL 100MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|8.25||||8.25||| 9513557|ERX|0250|LABETALOL 100MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8.25||||||| 9513557|ERX|0250|LABETALOL 100MG TABLET|Medicaid|MEDICAID|8.25||||||| 9513599|ERX|0250|ENALAPRIL 5MG TABLET|Medicare|MEDICARE ACUTE|0.15||||||| 9513599|ERX|0250|ENALAPRIL 5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.15||||||| 9513599|ERX|0250|ENALAPRIL 5MG TABLET|Humana Medicare Advantage|HUMANA MA|0.15||||0.15||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|21.50||||||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|21.50||||||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|United Healthcare|UMR UNITED MEDICAL RESOURCES|21.50||||||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|United Healthcare|UNITED HEALTHCARE|||||21.50||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|21.50||||21.50||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Humana Medicare Advantage|HUMANA MA|21.50||||21.50||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||21.50||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||21.50||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|21.50||||21.50||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|||||21.50||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|21.50||||21.50||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|21.50||||||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||21.50||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|||||21.50||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|21.50||||21.50||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|21.50||||21.50||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|21.50||||21.50||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||21.50||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||21.50||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Medicaid|MEDICAID|21.50||||21.50||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Medicaid|MEDICAID HMO|||||21.50||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|||||21.50||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Rusk State Hospital|RUSK STATE HOSP|21.50||||21.50||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|Medicare|MEDICARE ACUTE|21.50||||||| 9513623|ERX|0250|FAMOTIDINE 20MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|21.50||||21.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|NON CONTRACTED|COMMERCIAL OTHER 1|2.50||||||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Rusk State Hospital|RUSK STATE HOSP|2.50||||||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|2.50||||||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Medicaid|MEDICAID|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Medicaid|MEDICAID TEXAS CHILDRENS|||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Aenta Medicare Advantage|AETNA MEDICARE MA|2.50||||||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Blue Cross PPO Specialty|BCBSTX PPO|||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Blue Cross HMO Specialty|BCBSTX HMO|||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Managed Medicaid|MEDICAID AMERIGROUP|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Managed Medicaid|MEDICAID SUPERIOR|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Aetna|AETNA OTHER|||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|United Healthcare|UNITED HEALTHCARE|||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||2.50||| 9513631|ERX|0250|DIPHENHYDRAMINE 25MG CAPS|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|2.50||||2.50||| 9513656|ERX|0250|CARBIDOPA-LEVO SR 25-100M|Humana Medicare Advantage|HUMANA MA|13.75||||||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|13.50||||||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|13.50||||||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Medicare|MEDICARE ACUTE|13.50||||13.50||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|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||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|13.50||||||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|13.50||||||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||13.50||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|13.50||||||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Humana Medicare Advantage|HUMANA MA|13.50||||13.50||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|13.50||||||| 9513672|ERX|0250|LISINOPRIL 5MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|13.50||||||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Humana Medicare Advantage|HUMANA MA|0.15||||0.15||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.15||||||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.15||||||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.15||||||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.15||||0.15||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Aetna|AETNA OTHER|0.15||||||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|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|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.15||||0.15||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.15||||||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.15||||||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.15||||||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|0.15||||||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.15||||0.15||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Workers Compensation|UT EMPLOYEE INJURY|0.15||||||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|0.15||||||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 2|||||0.15||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Medicare|MEDICARE ACUTE|0.15||||0.15||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.15||||||| 9513680|ERX|0250|LISINOPRIL 20MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.15||||||| 9513706|ERX|0250|FLUVOXAMINE 100MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||26.25||| 9513714|ERX|0250|SULFASALAZINE 500MG TABLE|Humana Medicare Advantage|HUMANA MA|9.50||||||| 9513730|ERX|0250|SOLIFENACIN 5MG TABLET|Medicare|MEDICARE ACUTE|43.25||||43.25||| 9513730|ERX|0250|SOLIFENACIN 5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|43.25||||||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|1.63||||||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|Humana Medicare Advantage|HUMANA MA|1.63||||||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|Medicare|MEDICARE ACUTE|1.63||||||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|Rusk State Hospital|RUSK STATE HOSP|1.63||||||| 9513748|ERX|0250|CHLORHEXIDINE 0.12% ORAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.63||||||| 9513763|ERX|0250|BISOPROLOL-HCTZ 2.5-6.25M|Medicare|MEDICARE ACUTE|||||0.30||| 9513771|ERX|0250|BISOPROLOL-HCTZ 5-6.25MG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.30||||||| 9513771|ERX|0250|BISOPROLOL-HCTZ 5-6.25MG|Blue Cross HMO Specialty|BCBSTX HMO|0.30||||||| 9513771|ERX|0250|BISOPROLOL-HCTZ 5-6.25MG|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||0.30||| 9513771|ERX|0250|BISOPROLOL-HCTZ 5-6.25MG|Medicare|MEDICARE ACUTE|0.30||||||| 9513789|ERX|0250|BISOPROLOL 5MG TABLET|Medicare|MEDICARE ACUTE|0.30||||||| 9513789|ERX|0250|BISOPROLOL 5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.30||||||| 9513789|ERX|0250|BISOPROLOL 5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.30||||||| 9513789|ERX|0250|BISOPROLOL 5MG TABLET|Humana Medicare Advantage|HUMANA MA|0.30||||||| 9513789|ERX|0250|BISOPROLOL 5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.30||||||| 9513789|ERX|0250|BISOPROLOL 5MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.30||||||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Aenta Medicare Advantage|AETNA MEDICARE 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|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||449.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Blue Cross HMO Specialty|BCBSTX HMO|449.75||||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|Humana Medicare Advantage|HUMANA MA|449.75||||449.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||449.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|449.75||||||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Managed Medicaid|MEDICAID SUPERIOR|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 AMERIGROUP|449.75||||449.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|United Healthcare|UNITED HEALTHCARE OTHER|||||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|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|449.75||||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|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|449.75||||449.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|United Medicare Advantage|UHC MEDICARE GOLD MA|449.75||||||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Workers Compensation|WORKERS COMPENSATION OTHER|449.75||||449.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|United Healthcare|UNITED HEALTHCARE|449.75||||||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Managed Medicare|HEALTHSPRING MA|||||449.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||449.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|NON CONTRACTED|COMMERCIAL OTHER 1|449.75||||||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||449.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Medicare|MEDICARE ACUTE|449.75||||449.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|449.75||||449.75||| 9513912|ERX|0250|TRANEXAMIC 100MG/ML, 10ML|Tricare|TRICARE EAST REGION|449.75||||||| 9513938|ERX|0250|AZTREONAM 1000MG VIAL|Humana Medicare Advantage|HUMANA MA|359.50||||||| 9513938|ERX|0250|AZTREONAM 1000MG VIAL|Medicare|MEDICARE ACUTE|359.50||||||| 9513946|ERX|0250|AZTREONAM 2000MG VIAL|Medicare|MEDICARE ACUTE|646.25||||||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|Veterans Affairs|VETERANS ADMINISTRATION|||||2.23||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|||||2.23||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|Blue Cross HMO Specialty|BCBSTX HMO|||||2.23||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|Aetna|AETNA PPO|2.23||||||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.23||||||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2.23||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|Humana Medicare Advantage|HUMANA MA|2.23||||2.23||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|Medicaid|MEDICAID|2.23||||||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|NON CONTRACTED|COMMERCIAL OTHER 1|||||2.23||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|Rusk State Hospital|RUSK STATE HOSP|2.23||||||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|Medicare|MEDICARE ACUTE|2.23||||2.23||| 9513953|ERX|0250|CEFEPIME 1 G VIAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.23||||||| 9513961|ERX|0250|CEFEPIME 2 G VIAL|Medicare|MEDICARE ACUTE|4.43||||4.43||| 9513961|ERX|0250|CEFEPIME 2 G VIAL|Humana Medicare Advantage|HUMANA MA|4.43||||||| 9513961|ERX|0250|CEFEPIME 2 G VIAL|Blue Cross PPO Specialty|BCBSTX PPO|||||4.43||| 9513961|ERX|0250|CEFEPIME 2 G VIAL|Blue Cross HMO Specialty|BCBSTX HMO|4.43||||||| 9513961|ERX|0250|CEFEPIME 2 G VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4.43||||||| 9513961|ERX|0250|CEFEPIME 2 G VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||4.43||| 9514001|ERX|0250|NYSTATIN CREAM, 15 GM|Medicare|MEDICARE ACUTE|32.25||||||| 9514019|ERX|0250|CLOTRIMAZOLE 1% CREAM, 15|Humana Medicare Advantage|HUMANA MA|0.67||||||| 9514019|ERX|0250|CLOTRIMAZOLE 1% CREAM, 15|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||0.67||| 9514019|ERX|0250|CLOTRIMAZOLE 1% CREAM, 15|Medicare|MEDICARE ACUTE|0.67||||||| 9514019|ERX|0250|CLOTRIMAZOLE 1% CREAM, 15|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.67||||||| 9514043|ERX|0250|ACETAZOLAMIDE 250MG TABLE|Medicare|MEDICARE ACUTE|7.50||||7.50||| 9514043|ERX|0250|ACETAZOLAMIDE 250MG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|7.50||||||| 9514043|ERX|0250|ACETAZOLAMIDE 250MG TABLE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|7.50||||||| 9514043|ERX|0250|ACETAZOLAMIDE 250MG TABLE|Aenta Medicare Advantage|AETNA MEDICARE MA|7.50||||||| 9514043|ERX|0250|ACETAZOLAMIDE 250MG TABLE|Humana Medicare Advantage|HUMANA MA|7.50||||||| 9514076|ERX|0250|PRENATAL VIT-FE FUMARATE-|Managed Medicaid|MEDICAID UNITED HEALTHCARE|5.50||||||| 9514076|ERX|0250|PRENATAL VIT-FE FUMARATE-|Medicare|MEDICARE ACUTE|5.50||||||| 9514084|ERX|0250|PEG 3350, 4L|Blue Cross HMO Specialty|BCBSTX HMO|1.91||||||| 9514100|ERX|0250|LATANOPROST EYE DROP, 2.5|NON CONTRACTED|COMMERCIAL OTHER 1|7.43||||||| 9514100|ERX|0250|LATANOPROST EYE DROP, 2.5|Medicare|MEDICARE ACUTE|7.43||||||| 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|Blue Cross HMO Specialty|BCBSTX HMO|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|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|24.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Blue Cross PPO Specialty|BCBSTX OTHER|24.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Humana Medicare Advantage|HUMANA MA|24.50||||24.50||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|24.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|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||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|United Medicare Advantage|AARP UHC WEST COMPLETE MA|24.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Blue Cross PPO Specialty|BCBSTX PPO|24.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|24.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Workers Compensation|WORKERS COMPENSATION OTHER|24.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|United Healthcare|UNITED HEALTHCARE|24.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|24.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Medicaid|MOLINA HEALTHCARE OF TEXAS|24.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|United Medicare Advantage|UHC MEDICARE GOLD MA|24.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Rusk State Hospital|RUSK STATE HOSP|24.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|NON CONTRACTED|COMMERCIAL OTHER 1|24.50||||||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|Medicare|MEDICARE ACUTE|24.50||||24.50||| 9514118|ERX|0250|POLYETHYLENE GLYCOL 17 G|UTMB|UTMB CORRECTIONAL MANAGED CARE|24.50||||||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|NON CONTRACTED|COMMERCIAL OTHER 1|20.50||||20.50||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Rusk State Hospital|RUSK STATE HOSP|||||20.50||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Tricare|TRICARE EAST REGION|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|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||20.50||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Managed Medicare|HOSPICE OF EAST TEXAS|20.50||||||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Medicaid|MEDICAID|20.50||||20.50||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||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|United Medicare Advantage|AARP UHC WEST COMPLETE MA|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|Cigna|CIGNA|20.50||||||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Medicare|MEDICARE ACUTE|20.50||||20.50||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|20.50||||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|Managed Medicaid|MEDICAID UNITED HEALTHCARE|20.50||||20.50||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Workers Compensation|WORKERS COMPENSATION OTHER|20.50||||20.50||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Managed Medicaid|MEDICAID SUPERIOR|||||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|United Medicare Advantage|UHC MEDICARE GOLD MA|20.50||||20.50||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Aenta Medicare Advantage|AETNA MEDICARE MA|20.50||||20.50||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||20.50||| 9514191|ERX|0250|HYDROCOD-ACETAM 10-325MG|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||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|Blue Cross HMO Specialty|BCBSTX HMO|20.50||||20.50||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Aenta Medicare Advantage|AETNA MEDICARE MA|0.15||||0.15||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.15||||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|Blue Cross HMO Specialty|BCBSTX HMO|0.15||||0.15||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Aetna|AETNA PPO|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|Managed Medicaid|MEDICAID AMERIGROUP|||||0.15||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||0.15||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|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|Managed Medicaid|MEDICAID SUPERIOR|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|United Healthcare|UNITED HEALTHCARE|||||0.15||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.15||||0.15||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|United Healthcare|UMR UNITED MEDICAL RESOURCES|0.15||||||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|United Healthcare|UNITED HEALTHCARE OTHER|||||0.15||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|United Medicare Advantage|UHC MEDICARE GOLD 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|Veterans Affairs|VETERANS ADMINISTRATION|0.15||||0.15||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.15||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Managed Medicare|HEALTHSPRING MA|0.15||||||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|Medicaid|MEDICAID|0.15||||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|Medicare|MEDICARE ACUTE|0.15||||0.15||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.15||||||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|0.15||||||| 9514217|ERX|0250|HYDROCOD-ACETAM 7.5-325MG|United Medicare Advantage|AARP UHC WEST COMPLETE MA|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|Medicare|MEDICARE ACUTE|0.15||||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|HEALTHSPRING MA|0.15||||||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||0.15||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|United Healthcare|UNITED HEALTHCARE OTHER|||||0.15||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|United Healthcare|UNITED HEALTHCARE|||||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|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.15||||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|Veterans Affairs|VETERANS ADMINISTRATION|||||0.15||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Humana Medicare Advantage|HUMANA MA|0.15||||0.15||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Managed Medicaid|MEDICAID AMERIGROUP|||||0.15||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Brinson Benefits|THE HEALTH PLAN SMITH CO|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|Medicaid|MEDICAID|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|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.15||||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||| 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|Aenta Medicare Advantage|AETNA MEDICARE MA|||||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|Blue Cross HMO Specialty|BCBSTX HMO|||||0.15||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Blue Cross PPO Specialty|BCBSTX OTHER|0.15||||||| 9514225|ERX|0250|HYDROCOD-ACETAM 5-325MG T|Blue Cross PPO Specialty|BCBSTX PPO|0.15||||0.15||| 9514241|ERX|0250|FERRICGLUC CPLX/SUC 62.5M|Managed Medicaid|MEDICAID SUPERIOR|424.75||||||| 9514241|ERX|0250|FERRICGLUC CPLX/SUC 62.5M|United Medicare Advantage|UHC MEDICARE GOLD MA|424.75||||||| 9514241|ERX|0250|FERRICGLUC CPLX/SUC 62.5M|Medicare|MEDICARE ACUTE|424.75||||424.75||| 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-|Blue Cross PPO Specialty|BCBSTX PPO|20.25||||||| 9514274|ERX|0250|BUTAL-ACETAM-CAFF 50-325-|Managed Medicaid|MEDICAID SUPERIOR|20.25||||20.25||| 9514274|ERX|0250|BUTAL-ACETAM-CAFF 50-325-|Managed Medicaid|MEDICAID AMERIGROUP|||||20.25||| 9514274|ERX|0250|BUTAL-ACETAM-CAFF 50-325-|Humana Medicare Advantage|HUMANA MA|||||20.25||| 9514290|ERX|0250|HYDROCODONE-CHLORPHEN, 5M|Managed Medicare|HOSPICE OF EAST TEXAS|29.50||||||| 9514290|ERX|0250|HYDROCODONE-CHLORPHEN, 5M|United Medicare Advantage|AARP UHC WEST COMPLETE MA|29.50||||||| 9514290|ERX|0250|HYDROCODONE-CHLORPHEN, 5M|Veterans Affairs|VETERANS ADMINISTRATION|29.50||||||| 9514290|ERX|0250|HYDROCODONE-CHLORPHEN, 5M|Workers Compensation|UT EMPLOYEE INJURY|29.50||||||| 9514332|ERX|0250|METOLAZONE 5MG TABLET|Humana Medicare Advantage|HUMANA MA|24.50||||||| 9514332|ERX|0250|METOLAZONE 5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|24.50||||||| 9514332|ERX|0250|METOLAZONE 5MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|24.50||||||| 9514332|ERX|0250|METOLAZONE 5MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|24.50||||||| 9514332|ERX|0250|METOLAZONE 5MG TABLET|Medicare|MEDICARE ACUTE|24.50||||||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Managed Medicare|HEALTHSPRING MA|2.50||||||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.50||||||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Rusk State Hospital|RUSK STATE HOSP|2.50||||||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|2.50||||||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||2.50||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|2.50||||2.50||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 2|||||2.50||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|2.50||||||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|2.50||||||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Medicaid|MEDICAID|2.50||||||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|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|Aenta Medicare Advantage|AETNA MEDICARE MA|2.50||||||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.50||||||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.50||||||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|||||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 CIGNA HEALTHSPRING|2.50||||||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Cigna|CIGNA|2.50||||||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.50||||||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|2.50||||||| 9514357|ERX|0250|ASPIRIN EC 81MG TABLET|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 9514431|ERX|0250|MIDODRINE 5MG TABLET|Humana Medicare Advantage|HUMANA MA|30.25||||||| 9514431|ERX|0250|MIDODRINE 5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|30.25||||||| 9514431|ERX|0250|MIDODRINE 5MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|||||30.25||| 9514431|ERX|0250|MIDODRINE 5MG TABLET|Medicare|MEDICARE ACUTE|30.25||||30.25||| 9514589|ERX|0250|FISH OIL (OM3FA) 1000MG C|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||2.50||| 9514589|ERX|0250|FISH OIL (OM3FA) 1000MG C|Humana Medicare Advantage|HUMANA MA|2.50||||2.50||| 9514670|ERX|0250|ENALAPRILAT 1.25MG 1ML|Medicare|MEDICARE ACUTE|44.75||||||| 9514670|ERX|0250|ENALAPRILAT 1.25MG 1ML|Humana Medicare Advantage|HUMANA MA|44.75||||||| 9514670|ERX|0250|ENALAPRILAT 1.25MG 1ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|44.75||||||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||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 Medicare Advantage|AARP UHC WEST COMPLETE MA|0.18||||||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.18||||||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Aenta Medicare Advantage|AETNA MEDICARE MA|0.18||||||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.18||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Blue Cross HMO Specialty|BCBSTX HMO|||||0.18||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Aetna|AETNA PPO|||||0.18||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Blue Cross PPO Specialty|BCBSTX PPO|0.18||||0.18||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Blue Cross PPO Specialty|BCBSTX OTHER|||||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|Managed Medicaid|MEDICAID AMERIGROUP|0.18||||0.18||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Humana Medicare Advantage|HUMANA MA|||||0.18||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Managed Medicare|HEALTHSPRING MA|||||0.18||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Medicaid|MEDICAID|||||0.18||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|Medicare|MEDICARE ACUTE|0.18||||0.18||| 9514712|ERX|0250|FAMOTIDINE 20MG/2ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.18||||||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Rusk State Hospital|RUSK STATE HOSP|44.75||||44.75||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|44.75||||||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Medicare|MEDICARE ACUTE|44.75||||44.75||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|44.75||||44.75||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|44.75||||44.75||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Humana Medicare Advantage|HUMANA MA|44.75||||44.75||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|44.75||||||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|44.75||||||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|Blue Cross HMO Specialty|BCBSTX HMO|44.75||||44.75||| 9514720|ERX|0250|VECURONIUM 10MG VIAL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|44.75||||44.75||| 9514761|ERX|0250|AMIODARONE 150MG/3ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||122.25||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.85||||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 MEDICARE GOLD MA|1.85||||1.85||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Workers Compensation|WORKERS COMPENSATION OTHER|||||1.85||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|United Healthcare|UMR UNITED MEDICAL RESOURCES|1.85||||||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||1.85||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Blue Cross PPO Specialty|BCBSTX OTHER|||||1.85||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Blue Cross HMO Specialty|BCBSTX HMO|||||1.85||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.85||||1.85||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Aetna|AETNA PPO|1.85||||||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Aetna|AETNA OTHER|||||1.85||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Blue Cross PPO Specialty|BCBSTX PPO|||||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|Managed Medicaid|MEDICAID AMERIGROUP|||||1.85||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Cigna|CIGNA|||||1.85||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1.85||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Managed Medicaid|MEDICAID SUPERIOR|1.85||||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 CIGNA HEALTHSPRING|1.85||||1.85||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Humana Medicare Advantage|HUMANA MA|1.85||||1.85||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1.85||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Managed Medicare|HEALTHSPRING MA|||||1.85||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.85||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||1.85||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Medicaid|MEDICAID|||||1.85||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|NON CONTRACTED|COMMERCIAL OTHER 1|1.85||||1.85||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Rusk State Hospital|RUSK STATE HOSP|||||1.85||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||1.85||| 9514779|ERX|0250|DICYCLOMINE 10MG/ML, 2ML|Medicare|MEDICARE ACUTE|1.85||||1.85||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Medicare|MEDICARE PART B ONLY IP|29.75||||||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|29.75||||29.75||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Medicaid|MEDICAID|||||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|Managed Medicaid|MEDICAID SUPERIOR|29.75||||||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||29.75||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||29.75||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|29.75||||29.75||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||29.75||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Managed Medicare|HEALTHSPRING MA|29.75||||||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Humana Medicare Advantage|HUMANA MA|29.75||||29.75||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||29.75||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Aenta Medicare Advantage|AETNA MEDICARE MA|29.75||||||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Blue Cross PPO Specialty|BCBSTX PPO|||||29.75||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Medicare|MEDICARE ACUTE|29.75||||29.75||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Aetna|AETNA PPO|||||29.75||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Blue Cross PPO Specialty|BCBSTX OTHER|29.75||||||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Blue Cross HMO Specialty|BCBSTX HMO|||||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||||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|Veterans Affairs|VETERANS ADMINISTRATION|29.75||||29.75||| 9514803|ERX|0250|METOPROLOL 5MG/5ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||29.75||| 9514829|ERX|0250|TERBUTALINE 1MG/ML|United Healthcare|UNITED HEALTHCARE OTHER|59.25||||59.25||| 9514829|ERX|0250|TERBUTALINE 1MG/ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||59.25||| 9514829|ERX|0250|TERBUTALINE 1MG/ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|59.25||||||| 9514829|ERX|0250|TERBUTALINE 1MG/ML|Blue Cross PPO Specialty|BCBSTX PPO|59.25||||59.25||| 9514829|ERX|0250|TERBUTALINE 1MG/ML|Blue Cross HMO Specialty|BCBSTX HMO|59.25||||59.25||| 9514829|ERX|0250|TERBUTALINE 1MG/ML|Managed Medicaid|MEDICAID SUPERIOR|||||59.25||| 9514829|ERX|0250|TERBUTALINE 1MG/ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|59.25||||||| 9514829|ERX|0250|TERBUTALINE 1MG/ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||59.25||| 9514829|ERX|0250|TERBUTALINE 1MG/ML|Managed Medicaid|MEDICAID AMERIGROUP|59.25||||59.25||| 9514829|ERX|0250|TERBUTALINE 1MG/ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||59.25||| 9514829|ERX|0250|TERBUTALINE 1MG/ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||59.25||| 9514829|ERX|0250|TERBUTALINE 1MG/ML|NON CONTRACTED|COMMERCIAL OTHER 2|59.25||||||| 9514829|ERX|0250|TERBUTALINE 1MG/ML|NON CONTRACTED|COMMERCIAL OTHER 1|59.25||||||| 9514837|ERX|0250|DOXYCYCLINE 100MG VIAL|Humana Medicare Advantage|HUMANA MA|160.50||||||| 9514837|ERX|0250|DOXYCYCLINE 100MG VIAL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|160.50||||||| 9514837|ERX|0250|DOXYCYCLINE 100MG VIAL|Medicare|MEDICARE ACUTE|160.50||||||| 9514969|ERX|0250|OCTREOTIDE 50MCG/1ML|Humana Medicare Advantage|HUMANA MA|1.35||||||| 9514985|ERX|0250|OCTREOTIDE 500MCG/1ML|Humana Medicare Advantage|HUMANA MA|917.75||||||| 9514993|ERX|0250|BUTORPHANOL 2MG/1ML|Medicare|MEDICARE ACUTE|||||44.75||| 9514993|ERX|0250|BUTORPHANOL 2MG/1ML|United Healthcare|UMR UNITED MEDICAL RESOURCES|44.75||||||| 9514993|ERX|0250|BUTORPHANOL 2MG/1ML|United Healthcare|UNITED HEALTHCARE|||||44.75||| 9514993|ERX|0250|BUTORPHANOL 2MG/1ML|Workers Compensation|WORKERS COMPENSATION OTHER|||||44.75||| 9514993|ERX|0250|BUTORPHANOL 2MG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||44.75||| 9514993|ERX|0250|BUTORPHANOL 2MG/1ML|Aetna|AETNA PPO|44.75||||||| 9514993|ERX|0250|BUTORPHANOL 2MG/1ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|44.75||||||| 9514993|ERX|0250|BUTORPHANOL 2MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|44.75||||44.75||| 9514993|ERX|0250|BUTORPHANOL 2MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|44.75||||||| 9514993|ERX|0250|BUTORPHANOL 2MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||44.75||| 9514993|ERX|0250|BUTORPHANOL 2MG/1ML|Humana Medicare Advantage|HUMANA MA|44.75||||44.75||| 9515057|ERX|0250|ACETAZOLAMIDE 500MG VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|444.25||||||| 9515057|ERX|0250|ACETAZOLAMIDE 500MG VIAL|Humana Medicare Advantage|HUMANA MA|444.25||||||| 9515057|ERX|0250|ACETAZOLAMIDE 500MG VIAL|Medicare|MEDICARE ACUTE|444.25||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Managed Medicare|HEALTHSPRING MA|0.21||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|NON CONTRACTED|COMMERCIAL OTHER 1|0.21||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.21||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Medicare|MEDICARE ACUTE|0.21||||0.21||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Medicaid|MEDICAID|0.21||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Veterans Affairs|VETERANS ADMINISTRATION|0.21||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.21||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.21||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Rusk State Hospital|RUSK STATE HOSP|0.21||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.21||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Workers Compensation|UT EMPLOYEE INJURY|0.21||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.21||||0.21||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Aenta Medicare Advantage|AETNA MEDICARE MA|0.21||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.21||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Blue Cross HMO Specialty|BCBSTX HMO|0.21||||0.21||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Blue Cross PPO Specialty|BCBSTX PPO|0.21||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.21||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Managed Medicaid|MEDICAID SUPERIOR|0.21||||||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Humana Medicare Advantage|HUMANA MA|0.21||||0.21||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.21||||0.21||| 9515081|ERX|0250|BUMETANIDE 1MG/4ML|Blue Cross PPO Specialty|BCBSTX OTHER|0.21||||||| 9515123|ERX|0250|ACYCLOVIR 500MG VIAL|Managed Medicaid|MEDICAID SUPERIOR|1.14||||1.14||| 9515131|ERX|0250|ETOMIDATE 2MG/ML, 20ML|Medicare|MEDICARE ACUTE|1.38||||1.38||| 9515131|ERX|0250|ETOMIDATE 2MG/ML, 20ML|Humana Medicare Advantage|HUMANA MA|1.38||||||| 9515404|ERX|0250|HEPATITIS B VACCINE(PF) 0|United Healthcare|UNITED HEALTHCARE|2.62||||||| 9515404|ERX|0250|HEPATITIS B VACCINE(PF) 0|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.62||||||| 9515404|ERX|0250|HEPATITIS B VACCINE(PF) 0|Blue Cross PPO Specialty|BCBSTX PPO|2.62||||||| 9515404|ERX|0250|HEPATITIS B VACCINE(PF) 0|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.62||||||| 9515404|ERX|0250|HEPATITIS B VACCINE(PF) 0|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.62||||||| 9515404|ERX|0250|HEPATITIS B VACCINE(PF) 0|Blue Cross HMO Specialty|BCBSTX HMO|2.62||||||| 9515404|ERX|0250|HEPATITIS B VACCINE(PF) 0|Cigna|CIGNA|2.62||||||| 9515404|ERX|0250|HEPATITIS B VACCINE(PF) 0|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.62||||||| 9515404|ERX|0250|HEPATITIS B VACCINE(PF) 0|Managed Medicaid|MEDICAID SUPERIOR|2.62||||||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.16||||||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|Managed Medicare|HEALTHSPRING MA|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|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.16||||||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|Humana Medicare Advantage|HUMANA MA|0.16||||0.16||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|Aenta Medicare Advantage|AETNA MEDICARE MA|0.16||||||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|Blue Cross PPO Specialty|BCBSTX PPO|0.16||||||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|Blue Cross PPO Specialty|BCBSTX OTHER|0.16||||||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.16||||0.16||| 9515420|ERX|0250|ISOSORBIDE MONONITRATE 30|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.16||||0.16||| 9515446|ERX|0250|KETOROLAC 10MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|||||13.75||| 9515446|ERX|0250|KETOROLAC 10MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|||||13.75||| 9515446|ERX|0250|KETOROLAC 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||13.75||| 9515446|ERX|0250|KETOROLAC 10MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|||||13.75||| 9515446|ERX|0250|KETOROLAC 10MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||13.75||| 9515446|ERX|0250|KETOROLAC 10MG TABLET|Humana Medicare Advantage|HUMANA MA|||||13.75||| 9515446|ERX|0250|KETOROLAC 10MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|13.75||||||| 9515446|ERX|0250|KETOROLAC 10MG TABLET|Medicaid|MEDICAID|||||13.75||| 9515446|ERX|0250|KETOROLAC 10MG TABLET|Medicaid|MEDICAID TEXAS CHILDRENS|||||13.75||| 9515446|ERX|0250|KETOROLAC 10MG TABLET|Medicare|MEDICARE ACUTE|||||13.75||| 9515446|ERX|0250|KETOROLAC 10MG TABLET|Tricare|TRICARE EAST REGION|||||13.75||| 9515487|ERX|0250|NITROGLYCERIN 0.4MG TABLE|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.04||| 9515487|ERX|0250|NITROGLYCERIN 0.4MG TABLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|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|Cigna|CIGNA|||||0.04||| 9515487|ERX|0250|NITROGLYCERIN 0.4MG TABLE|Managed Medicaid|MEDICAID AMERIGROUP|||||0.04||| 9515487|ERX|0250|NITROGLYCERIN 0.4MG TABLE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||0.04||| 9515487|ERX|0250|NITROGLYCERIN 0.4MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.04||| 9515487|ERX|0250|NITROGLYCERIN 0.4MG TABLE|Managed Medicaid|MEDICAID SUPERIOR|||||0.04||| 9515487|ERX|0250|NITROGLYCERIN 0.4MG TABLE|Humana Medicare Advantage|HUMANA MA|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|Blue Cross PPO Specialty|BCBSTX PPO|0.04||||0.04||| 9515487|ERX|0250|NITROGLYCERIN 0.4MG TABLE|Medicare|MEDICARE PART B ONLY IP|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|Blue Cross HMO Specialty|BCBSTX HMO|||||0.04||| 9515487|ERX|0250|NITROGLYCERIN 0.4MG TABLE|Aetna|AETNA PPO|||||0.04||| 9515487|ERX|0250|NITROGLYCERIN 0.4MG TABLE|United Healthcare|GEHA|||||0.04||| 9515487|ERX|0250|NITROGLYCERIN 0.4MG TABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.04||||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|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||0.04||| 9515487|ERX|0250|NITROGLYCERIN 0.4MG TABLE|Veterans Affairs|VETERANS ADMINISTRATION|||||0.04||| 9515487|ERX|0250|NITROGLYCERIN 0.4MG TABLE|Medicaid|MEDICAID|||||0.04||| 9515628|ERX|0250|SEVELAMER 800MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.18||| 9515628|ERX|0250|SEVELAMER 800MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.18||||||| 9515628|ERX|0250|SEVELAMER 800MG TABLET|Medicare|MEDICARE ACUTE|0.18||||||| 9515644|ERX|0250|CHOLECALCIFEROL 1000 UNIT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|12.25||||||| 9515644|ERX|0250|CHOLECALCIFEROL 1000 UNIT|Medicaid|COUNTY INDIGENT HEALTH OTHER|12.25||||||| 9515644|ERX|0250|CHOLECALCIFEROL 1000 UNIT|Rusk State Hospital|RUSK STATE HOSP|12.25||||||| 9515644|ERX|0250|CHOLECALCIFEROL 1000 UNIT|Medicare|MEDICARE ACUTE|12.25||||12.25||| 9515644|ERX|0250|CHOLECALCIFEROL 1000 UNIT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12.25||||||| 9515644|ERX|0250|CHOLECALCIFEROL 1000 UNIT|Aenta Medicare Advantage|AETNA MEDICARE MA|12.25||||||| 9515644|ERX|0250|CHOLECALCIFEROL 1000 UNIT|Blue Cross PPO Specialty|BCBSTX PPO|12.25||||12.25||| 9515644|ERX|0250|CHOLECALCIFEROL 1000 UNIT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|12.25||||||| 9515644|ERX|0250|CHOLECALCIFEROL 1000 UNIT|Humana Medicare Advantage|HUMANA MA|12.25||||12.25||| 9515644|ERX|0250|CHOLECALCIFEROL 1000 UNIT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|12.25||||12.25||| 9515644|ERX|0250|CHOLECALCIFEROL 1000 UNIT|United Medicare Advantage|UHC MEDICARE GOLD MA|12.25||||||| 9515644|ERX|0250|CHOLECALCIFEROL 1000 UNIT|United Medicare Advantage|AARP UHC WEST COMPLETE MA|12.25||||||| 9515701|ERX|0250|OXYCODONE SR 20MG TABLET|Medicare|MEDICARE ACUTE|||||35.50||| 9515750|ERX|0250|ARIPIPRAZOLE 2MG TABLET|Humana Medicare Advantage|HUMANA MA|0.21||||||| 9515750|ERX|0250|ARIPIPRAZOLE 2MG TABLET|Medicare|MEDICARE ACUTE|0.21||||||| 9515776|ERX|0250|ARIPIPRAZOLE 10MG TABLET|Medicare|MEDICARE ACUTE|144.25||||||| 9515776|ERX|0250|ARIPIPRAZOLE 10MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|144.25||||||| 9515776|ERX|0250|ARIPIPRAZOLE 10MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||144.25||| 9515776|ERX|0250|ARIPIPRAZOLE 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||144.25||| 9515776|ERX|0250|ARIPIPRAZOLE 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|144.25||||||| 9515776|ERX|0250|ARIPIPRAZOLE 10MG TABLET|Humana Medicare Advantage|HUMANA MA|144.25||||144.25||| 9515792|ERX|0250|OLANZAPINE 10MG/2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||239.25||| 9515792|ERX|0250|OLANZAPINE 10MG/2ML|Humana Medicare Advantage|HUMANA MA|239.25||||||| 9515792|ERX|0250|OLANZAPINE 10MG/2ML|Rusk State Hospital|RUSK STATE HOSP|||||239.25||| 9515792|ERX|0250|OLANZAPINE 10MG/2ML|Medicare|MEDICARE ACUTE|239.25||||||| 9515925|ERX|0250|NITROGLYCERIN SPRAY|Medicare|MEDICARE ACUTE|||||1,714.50||| 9515925|ERX|0250|NITROGLYCERIN SPRAY|Humana Medicare Advantage|HUMANA MA|1,714.50||||||| 9515941|ERX|0250|ORAPRED SOLUTION 15MG/5ML|United Healthcare|UNITED HEALTHCARE|36.75||||36.75||| 9515941|ERX|0250|ORAPRED SOLUTION 15MG/5ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||36.75||| 9515941|ERX|0250|ORAPRED SOLUTION 15MG/5ML|Blue Cross PPO Specialty|BCBSTX PPO|||||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|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||36.75||| 9515941|ERX|0250|ORAPRED SOLUTION 15MG/5ML|Managed Medicaid|MEDICAID AMERIGROUP|36.75||||36.75||| 9515941|ERX|0250|ORAPRED SOLUTION 15MG/5ML|Managed Medicaid|MEDICAID SUPERIOR|36.75||||36.75||| 9515941|ERX|0250|ORAPRED SOLUTION 15MG/5ML|Medicaid|MEDICAID HMO|||||36.75||| 9515941|ERX|0250|ORAPRED SOLUTION 15MG/5ML|Medicaid|MEDICAID|36.75||||36.75||| 9515941|ERX|0250|ORAPRED SOLUTION 15MG/5ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||36.75||| 9515941|ERX|0250|ORAPRED SOLUTION 15MG/5ML|Medicaid|MEDICAID TEXAS CHILDRENS|||||36.75||| 9515941|ERX|0250|ORAPRED SOLUTION 15MG/5ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||36.75||| 9515941|ERX|0250|ORAPRED SOLUTION 15MG/5ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||36.75||| 9515941|ERX|0250|ORAPRED SOLUTION 15MG/5ML|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||36.75||| 9515941|ERX|0250|ORAPRED SOLUTION 15MG/5ML|Tricare|TRICARE EAST REGION|||||36.75||| 9515974|ERX|0250|CALCIUM ACETATE 667MG TAB|Humana Medicare Advantage|HUMANA MA|2.75||||||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|Rusk State Hospital|RUSK STATE HOSP|0.46||||||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|Medicare|MEDICARE ACUTE|0.46||||0.46||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|Managed Medicare|HEALTHSPRING MA|0.46||||||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.46||||||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|Medicaid|MEDICAID|0.46||||0.46||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|0.46||||||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.46||||0.46||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.46||||||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|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 Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.46||||||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.46||||||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.46||||||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|0.46||||0.46||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.46||||||| 9516048|ERX|0250|ZOLPIDEM 5MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|0.46||||0.46||| 9516055|ERX|0250|NIACIN SR 500MG TABLET|Humana Medicare Advantage|HUMANA MA|24.50||||24.50||| 9516055|ERX|0250|NIACIN SR 500MG TABLET|Medicare|MEDICARE ACUTE|24.50||||||| 9516071|ERX|0250|METHIMAZOLE 10MG TABLET|Humana Medicare Advantage|HUMANA MA|||||0.18||| 9516147|ERX|0250|ZALEPLON 5MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|40.50||||||| 9516204|ERX|0250|NADOLOL 40MG TABLET|Humana Medicare Advantage|HUMANA MA|0.31||||||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Managed Medicare|HOSPICE OF EAST TEXAS|25.75||||||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|25.75||||25.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Medicaid|MEDICAID TEXAS CHILDRENS|||||25.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Medicaid|MEDICAID HMO|||||25.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||25.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Medicare|MEDICARE PART B ONLY IP|25.75||||||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|25.75||||25.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Medicare|MEDICARE ACUTE|25.75||||25.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|United Healthcare|UNITED HEALTHCARE|||||25.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Workers Compensation|UT EMPLOYEE INJURY|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|Rusk State Hospital|RUSK STATE HOSP|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|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|25.75||||25.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Workers Compensation|WORKERS COMPENSATION OTHER|25.75||||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|Aenta Medicare Advantage|AETNA MEDICARE MA|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|Medicaid|MEDICAID|25.75||||25.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|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|Blue Cross HMO Specialty|BCBSTX HMO|25.75||||25.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Aetna|AETNA OTHER|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|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||25.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|25.75||||25.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|25.75||||25.75||| 9516246|ERX|0250|LORAZEPAM 2MG/1ML|Managed Medicaid|MEDICAID AMERIGROUP|25.75||||25.75||| 9516253|ERX|0250|LORAZEPAM 20MG/10ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|99.75||||||| 9516253|ERX|0250|LORAZEPAM 20MG/10ML|Rusk State Hospital|RUSK STATE HOSP|99.75||||||| 9516287|ERX|0250|DOXAPRAM 400MG/20ML|Managed Medicaid|MEDICAID AMERIGROUP|||||493.75||| 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|Medicaid|MEDICAID|12.50||||12.50||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||12.50||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|12.50||||12.50||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Medicare|MEDICARE ACUTE|12.50||||12.50||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|12.50||||12.50||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Tricare|TRICARE EAST REGION|12.50||||12.50||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|12.50||||||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|United Healthcare|UNITED HEALTHCARE OTHER|12.50||||12.50||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|United Healthcare|UNITED HEALTHCARE|12.50||||12.50||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|United Healthcare|UNITED HEALTHCARE|||||12.50||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Workers Compensation|WORKERS COMPENSATION OTHER|12.50||||12.50||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|12.50||||12.50||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|12.50||||12.50||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|12.50||||12.50||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||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|Veterans Affairs|VETERANS ADMINISTRATION|12.50||||||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12.50||||12.50||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|12.50||||12.50||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|12.50||||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 HMO Specialty|BCBSTX HMO|12.50||||12.50||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Aetna|AETNA PPO|12.50||||12.50||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Managed Medicare|HEALTHSPRING MA|12.50||||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 PPO Specialty|BCBSTX OTHER|||||12.50||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Humana Medicare Advantage|HUMANA MA|12.50||||12.50||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|12.50||||12.50||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Cigna|CIGNA|||||12.50||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Managed Medicaid|MEDICAID AMERIGROUP|12.50||||12.50||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|12.50||||12.50||| 9516311|ERX|0250|GLYCOPYRROLATE 0.2MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|12.50||||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||||12.50||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Humana Medicare Advantage|HUMANA MA|0.28||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Cigna|CIGNA|||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Managed Medicaid|MEDICAID AMERIGROUP|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|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.28||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||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|Blue Cross HMO Specialty|BCBSTX HMO|0.28||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.28||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Aenta Medicare Advantage|AETNA MEDICARE MA|0.28||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Aetna|AETNA OTHER|||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Aetna|AETNA PPO|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|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|United Healthcare|UMR UNITED MEDICAL RESOURCES|0.28||||||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.28||||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|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Workers Compensation|WORKERS COMPENSATION OTHER|0.28||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Veterans Affairs|VETERANS ADMINISTRATION|0.28||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|NON CONTRACTED|COMMERCIAL OTHER 1|0.28||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Rusk State Hospital|RUSK STATE HOSP|0.28||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Medicare|MEDICARE ACUTE|0.28||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Managed Medicare|HEALTHSPRING MA|0.28||||||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Medicaid|MEDICAID|0.28||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||0.28||| 9516345|ERX|0250|METOCLOPRAMIDE 10MG/2ML|Medicaid|MEDICAID TEXAS CHILDRENS|||||0.28||| 9516352|ERX|0250|BRIMONIDINE 0.2% EYE DROP|Medicare|MEDICARE ACUTE|232.75||||||| 9516352|ERX|0250|BRIMONIDINE 0.2% EYE DROP|Humana Medicare Advantage|HUMANA MA|232.75||||232.75||| 9516386|ERX|0250|TIMOLOL GEL 0.5% EYE DROP|Humana Medicare Advantage|HUMANA MA|||||306.50||| 9516394|ERX|0250|GENTAMICIN EYE DROP, 5ML|Medicare|MEDICARE ACUTE|98.75||||||| 9516469|ERX|0250|NEOMYC-POLYMYX-HC ,10ML|Blue Cross PPO Specialty|BCBSTX PPO|||||776.50||| 9516469|ERX|0250|NEOMYC-POLYMYX-HC ,10ML|Managed Medicaid|MEDICAID SUPERIOR|||||776.50||| 9516469|ERX|0250|NEOMYC-POLYMYX-HC ,10ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||776.50||| 9516469|ERX|0250|NEOMYC-POLYMYX-HC ,10ML|Managed Medicaid|MEDICAID AMERIGROUP|||||776.50||| 9516469|ERX|0250|NEOMYC-POLYMYX-HC ,10ML|Medicaid|MEDICAID|||||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 UNITED HEALTHCARE|||||776.50||| 9516477|ERX|0250|NEOMYC-POLYMYX-HC EAR,10M|Managed Medicaid|MEDICAID AMERIGROUP|||||776.50||| 9516576|ERX|0250|RAMIPRIL 2.5MG CAPSULE|Medicare|MEDICARE ACUTE|25.25||||||| 9516584|ERX|0250|RAMIPRIL 5MG CAPSULE|Medicare|MEDICARE ACUTE|24.50||||||| 9516634|ERX|0250|FLUDROCORTISONE 0.1MG TAB|Workers Compensation|WORKERS COMPENSATION OTHER|||||0.15||| 9516634|ERX|0250|FLUDROCORTISONE 0.1MG TAB|Medicare|MEDICARE ACUTE|0.15||||||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|Medicaid|MEDICAID|0.37||||0.37||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|Tricare|TRICARE EAST REGION|0.37||||||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|Medicare|MEDICARE ACUTE|||||0.37||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.37||||||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|Aenta Medicare Advantage|AETNA MEDICARE MA|0.37||||||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|Blue Cross HMO Specialty|BCBSTX HMO|0.37||||||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|Aetna|AETNA PPO|0.37||||||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|Blue Cross PPO Specialty|BCBSTX PPO|0.37||||||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|Humana Medicare Advantage|HUMANA MA|||||0.37||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|Managed Medicaid|MEDICAID AMERIGROUP|0.37||||||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.37||||||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.37||||0.37||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|Managed Medicaid|MEDICAID SUPERIOR|0.37||||||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|United Healthcare|UMR UNITED MEDICAL RESOURCES|0.37||||0.37||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.37||||||| 9516659|ERX|0250|BUTORPHANOL 1MG/ML|Workers Compensation|WORKERS COMPENSATION OTHER|||||0.37||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|United Medicare Advantage|AARP UHC WEST COMPLETE MA|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|Veterans Affairs|VETERANS ADMINISTRATION|93.50||||||| 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|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||||||| 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|Managed Medicaid|MEDICAID AMERIGROUP|||||93.50||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Managed Medicaid|MEDICAID SUPERIOR|93.50||||93.50||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Blue Cross HMO Specialty|BCBSTX HMO|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|UTMB|UTMB CORRECTIONAL MANAGED CARE|93.50||||||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Medicare|MEDICARE PART B ONLY IP|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|Managed Medicare|HEALTHSPRING MA|93.50||||||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Medicaid|MEDICAID|93.50||||93.50||| 9516675|ERX|0250|MVI,ADULT NO.1 W/ VIT K 1|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||93.50||| 9516725|ERX|0250|EMTRICIT-TENOFOVIR 200-30|Workers Compensation|WORKERS COMPENSATION OTHER|||||345.50||| 9516790|ERX|0250|DONEPEZIL 5MG TABLET|Medicaid|MEDICAID|65.50||||||| 9516790|ERX|0250|DONEPEZIL 5MG TABLET|Medicare|MEDICARE ACUTE|65.50||||||| 9516790|ERX|0250|DONEPEZIL 5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|65.50||||||| 9516790|ERX|0250|DONEPEZIL 5MG TABLET|Humana Medicare Advantage|HUMANA MA|65.50||||65.50||| 9516790|ERX|0250|DONEPEZIL 5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|65.50||||||| 9516873|ERX|0250|CYCLOSPORINE 0.05% UD OPT|Managed Medicaid|MEDICAID UNITED HEALTHCARE|33.75||||||| 9516873|ERX|0250|CYCLOSPORINE 0.05% UD OPT|Medicare|MEDICARE ACUTE|33.75||||||| 9517012|ERX|0250|AMOX-CLAV 200-28.5MG/5ML,|Medicaid|MEDICAID|182.25||||||| 9517012|ERX|0250|AMOX-CLAV 200-28.5MG/5ML,|Medicare|MEDICARE ACUTE|182.25||||||| 9517012|ERX|0250|AMOX-CLAV 200-28.5MG/5ML,|Blue Cross PPO Specialty|BCBSTX OTHER|||||182.25||| 9517012|ERX|0250|AMOX-CLAV 200-28.5MG/5ML,|Managed Medicaid|MEDICAID SUPERIOR|||||182.25||| 9517012|ERX|0250|AMOX-CLAV 200-28.5MG/5ML,|Managed Medicaid|MEDICAID AMERIGROUP|||||182.25||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|United Healthcare|UNITED HEALTHCARE|0.56||||||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|United Healthcare|UNITED HEALTHCARE OTHER|0.56||||||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|Cigna|CIGNA|0.56||||||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.56||||||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|Managed Medicaid|MEDICAID SUPERIOR|0.56||||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||||||| 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 UHSS UT HLTH|0.56||||||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|Blue Cross HMO Specialty|BCBSTX HMO|0.56||||||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|Blue Cross PPO Specialty|BCBSTX 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 Medicare|HEALTHSPRING MA|0.56||||||| 9517038|ERX|0250|OXYTOCIN 10 UNIT/1ML|Medicaid|MEDICAID|0.56||||||| 9517053|ERX|0250|BIMATOPROST 0.03% DROP,2.|Medicare|MEDICARE ACUTE|7.89||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12.75||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|Aenta Medicare Advantage|AETNA MEDICARE MA|12.75||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|Blue Cross PPO Specialty|BCBSTX PPO|12.75||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|Blue Cross HMO Specialty|BCBSTX HMO|12.75||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|Humana Medicare Advantage|HUMANA MA|12.75||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|12.75||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|United Medicare Advantage|UHC MEDICARE GOLD MA|12.75||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|12.75||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|Medicaid|MEDICAID|12.75||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|NON CONTRACTED|COMMERCIAL OTHER 1|12.75||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|Rusk State Hospital|RUSK STATE HOSP|12.75||||||| 9517061|ERX|0250|MAGNESIUM SULFATE 4 MEQ/M|Medicare|MEDICARE ACUTE|12.75||||||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Medicare|MEDICARE ACUTE|44.75||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|United Healthcare|UNITED HEALTHCARE|||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|United Healthcare|GEHA|||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Humana Medicare Advantage|HUMANA MA|44.75||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Managed Medicaid|MEDICAID AMERIGROUP|||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Blue Cross HMO Specialty|BCBSTX HMO|||||44.75||| 9517103|ERX|0250|KETOROLAC 15MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|||||44.75||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Blue Cross PPO Specialty|BCBSTX OTHER|||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|59.25||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UMR|||||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|Blue Cross HMO Specialty|BCBSTX HMO|59.25||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Aetna|AETNA PPO|59.25||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Aetna|AETNA 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|Humana Medicare Advantage|HUMANA MA|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|Cigna|CIGNA|59.25||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Cigna|CIGNA|||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|59.25||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Managed Medicaid|MEDICAID AMERIGROUP|59.25||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|59.25||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|United Healthcare|UMR UNITED MEDICAL RESOURCES|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|United Healthcare|UNITED HEALTHCARE OTHER|59.25||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|United Healthcare|UNITED HEALTHCARE|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 DUAL COMPLETE HMO SNP MA|59.25||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|59.25||||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|AARP UHC WEST COMPLETE MA|59.25||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|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|Veterans Affairs|VETERANS ADMINISTRATION|59.25||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Managed Medicare|HEALTHSPRING MA|59.25||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||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 Medicare|BCBS MEDICARE PPO MA|||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Managed Medicare|HOSPICE OF EAST TEXAS|59.25||||||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Medicaid|MEDICAID|59.25||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||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|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|59.25||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Medicaid|MEDICAID TEXAS CHILDRENS|||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|59.25||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Rusk State Hospital|RUSK STATE HOSP|||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|59.25||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Tricare|TRICARE EAST REGION|59.25||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||59.25||| 9517111|ERX|0250|KETOROLAC 30MG/1ML|Medicare|MEDICARE ACUTE|59.25||||59.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Tricare|TRICARE EAST REGION|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Managed Medicare|HEALTHSPRING MA|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Medicaid|MEDICAID|||||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|UMR UNITED MEDICAL RESOURCES|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Workers Compensation|WORKERS COMPENSATION OTHER|71.25||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Workers Compensation|UT EMPLOYEE INJURY|||||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|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|71.25||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Veterans Affairs|VETERANS ADMINISTRATION|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Humana Medicare Advantage|HUMANA MA|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Medicare|MEDICARE ACUTE|71.25||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Managed Medicaid|MEDICAID SUPERIOR|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Cigna|CIGNA|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Managed Medicaid|MEDICAID AMERIGROUP|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Access Direct Platinum|HEALTHFIRST TPA UMR|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Blue Cross HMO Specialty|BCBSTX HMO|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Blue Cross PPO Specialty|BCBSTX PPO|||||71.25||| 9517129|ERX|0250|KETOROLAC 60MG/2ML|Blue Cross PPO Specialty|BCBSTX OTHER|||||71.25||| 9517137|ERX|0250|GENTAMICIN PF 10MG/ML, 2M|Managed Medicaid|MEDICAID SUPERIOR|0.59||||||| 9517137|ERX|0250|GENTAMICIN PF 10MG/ML, 2M|Managed Medicaid|MEDICAID AMERIGROUP|0.59||||||| 9517137|ERX|0250|GENTAMICIN PF 10MG/ML, 2M|Medicaid|MEDICAID|0.59||||||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.20||||||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Medicare|MEDICARE PART B ONLY IP|2.20||||||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Medicare|MEDICARE ACUTE|2.20||||||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||2.20||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Medicaid|MEDICAID|2.20||||2.20||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|United Medicare Advantage|UHC MEDICARE GOLD MA|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|United Medicare Advantage|AARP UHC WEST COMPLETE MA|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|Blue Cross HMO Specialty|BCBSTX HMO|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|Managed Medicaid|MEDICAID SUPERIOR|2.20||||2.20||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Cigna|CIGNA|2.20||||||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.20||||||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Managed Medicaid|MEDICAID AMERIGROUP|||||2.20||| 9517145|ERX|0250|FOLIC ACID 5MG/ML, 10ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.20||||||| 9517160|ERX|0250|PROTAMINE 250MG/25ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|207.75||||||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|NON CONTRACTED|COMMERCIAL OTHER 1|865.25||||||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Rusk State Hospital|RUSK STATE HOSP|865.25||||865.25||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|865.25||||865.25||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Medicaid|MEDICAID|865.25||||||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Medicare|MEDICARE ACUTE|865.25||||865.25||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|United Healthcare|UNITED HEALTHCARE OTHER|||||865.25||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|865.25||||865.25||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||865.25||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Aenta Medicare Advantage|AETNA MEDICARE MA|865.25||||||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Blue Cross HMO Specialty|BCBSTX HMO|865.25||||865.25||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Blue Cross PPO Specialty|BCBSTX PPO|||||865.25||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Humana Medicare Advantage|HUMANA MA|865.25||||865.25||| 9517194|ERX|0250|PROPOFOL 1000MG/100ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|865.25||||865.25||| 9517236|ERX|0250|TOBRAMYCIN 40MG/ML, 2ML|Aenta Medicare Advantage|AETNA MEDICARE MA|0.50||||||| 9517236|ERX|0250|TOBRAMYCIN 40MG/ML, 2ML|Medicare|MEDICARE ACUTE|0.50||||||| 9517236|ERX|0250|TOBRAMYCIN 40MG/ML, 2ML|Medicaid|MEDICAID|0.50||||||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|15.75||||||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Rusk State Hospital|RUSK STATE HOSP|15.75||||||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|UTMB|UTMB CORRECTIONAL MANAGED CARE|15.75||||15.75||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Medicare|MEDICARE ACUTE|15.75||||15.75||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|United Healthcare|UNITED HEALTHCARE|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|UHC DUAL COMPLETE HMO SNP MA|15.75||||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,|Veterans Affairs|VETERANS ADMINISTRATION|15.75||||||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Humana Medicare Advantage|HUMANA MA|15.75||||15.75||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Managed Medicaid|MEDICAID SUPERIOR|15.75||||||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|15.75||||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,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|15.75||||||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Aenta Medicare Advantage|AETNA MEDICARE MA|15.75||||15.75||| 9517244|ERX|0250|CA GLUC 10% 0.465 MEQ/ML,|Blue Cross PPO Specialty|BCBSTX PPO|15.75||||||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||124.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||124.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||124.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Blue Cross HMO Specialty|BCBSTX HMO|||||124.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Aetna|AETNA PPO|||||124.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|124.25||||124.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Humana Medicare Advantage|HUMANA MA|124.25||||124.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||124.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|124.25||||||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|124.25||||||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|124.25||||124.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|124.25||||124.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Managed Medicaid|MEDICAID AMERIGROUP|124.25||||124.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|United Healthcare|UNITED HEALTHCARE OTHER|124.25||||||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||124.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|124.25||||124.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|124.25||||124.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|124.25||||124.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|124.25||||124.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Tricare|TRICARE EAST REGION|||||124.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Medicare|MEDICARE ACUTE|124.25||||124.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Managed Medicare|HEALTHSPRING MA|124.25||||||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||124.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Medicaid|MEDICAID|124.25||||124.25||| 9517293|ERX|0250|NEOSTIGMINE 1MG/1ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||124.25||| 9517301|ERX|0250|AMPICILLIN 250MG VIAL|Medicaid|MEDICAID|0.37||||0.37||| 9517301|ERX|0250|AMPICILLIN 250MG VIAL|Managed Medicaid|MEDICAID AMERIGROUP|0.37||||||| 9517301|ERX|0250|AMPICILLIN 250MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|0.37||||||| 9517319|ERX|0250|AMPICILLIN 500MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|57.75||||||| 9517319|ERX|0250|AMPICILLIN 500MG VIAL|Managed Medicaid|MEDICAID SUPERIOR|57.75||||||| 9517319|ERX|0250|AMPICILLIN 500MG VIAL|Managed Medicaid|MEDICAID AMERIGROUP|57.75||||||| 9517319|ERX|0250|AMPICILLIN 500MG VIAL|Medicaid|MEDICAID|57.75||||||| 9517327|ERX|0250|AMPICILLIN 1000MG VIAL|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||83.75||| 9517327|ERX|0250|AMPICILLIN 1000MG VIAL|Medicaid|MEDICAID|83.75||||||| 9517327|ERX|0250|AMPICILLIN 1000MG VIAL|Managed Medicaid|MEDICAID SUPERIOR|83.75||||||| 9517327|ERX|0250|AMPICILLIN 1000MG VIAL|Managed Medicaid|MEDICAID AMERIGROUP|83.75||||||| 9517327|ERX|0250|AMPICILLIN 1000MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|83.75||||||| 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||||1.63||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Veterans Affairs|VETERANS ADMINISTRATION|1.63||||||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Workers Compensation|UT EMPLOYEE INJURY|1.63||||||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|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 HMO Specialty|BCBSTX HMO|||||1.63||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|1.63||||1.63||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|1.63||||||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Humana Medicare Advantage|HUMANA MA|1.63||||1.63||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|1.63||||||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Cigna|CIGNA|||||1.63||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|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|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1.63||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Managed Medicaid|MEDICAID AMERIGROUP|||||1.63||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||1.63||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Rusk State Hospital|RUSK STATE HOSP|1.63||||||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.63||||1.63||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Medicare|MEDICARE ACUTE|1.63||||1.63||| 9517376|ERX|0250|HYDRALAZINE 20MG/1ML|Medicaid|MEDICAID|||||1.63||| 9517392|ERX|0250|PENTAMIDINE NEB 300MG VIA|Medicare|MEDICARE ACUTE|||||975.50||| 9517467|ERX|0250|LEVALBUTEROL NEB 0.63MG/3|Humana Medicare Advantage|HUMANA MA|93.75||||||| 9517467|ERX|0250|LEVALBUTEROL NEB 0.63MG/3|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|93.75||||||| 9517467|ERX|0250|LEVALBUTEROL NEB 0.63MG/3|Managed Medicaid|MEDICAID SUPERIOR|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|Veterans Affairs|VETERANS ADMINISTRATION|93.75||||||| 9517467|ERX|0250|LEVALBUTEROL NEB 0.63MG/3|United Medicare Advantage|UHC MEDICARE GOLD MA|93.75||||||| 9517467|ERX|0250|LEVALBUTEROL NEB 0.63MG/3|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|93.75||||||| 9517467|ERX|0250|LEVALBUTEROL NEB 0.63MG/3|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||93.75||| 9517467|ERX|0250|LEVALBUTEROL NEB 0.63MG/3|Medicare|MEDICARE ACUTE|93.75||||93.75||| 9517475|ERX|0250|LEVALBUTEROL NEB 1.25MG/3|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||93.75||| 9517475|ERX|0250|LEVALBUTEROL NEB 1.25MG/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|UHC MEDICARE GOLD MA|93.75||||||| 9517475|ERX|0250|LEVALBUTEROL NEB 1.25MG/3|Veterans Affairs|VETERANS ADMINISTRATION|93.75||||||| 9517475|ERX|0250|LEVALBUTEROL NEB 1.25MG/3|Humana Medicare Advantage|HUMANA MA|93.75||||93.75||| 9517475|ERX|0250|LEVALBUTEROL NEB 1.25MG/3|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||93.75||| 9517475|ERX|0250|LEVALBUTEROL NEB 1.25MG/3|Managed Medicaid|MEDICAID SUPERIOR|93.75||||||| 9517475|ERX|0250|LEVALBUTEROL NEB 1.25MG/3|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|93.75||||||| 9517483|ERX|0250|MODAFINIL 100MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|76.75||||||| 9517483|ERX|0250|MODAFINIL 100MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|76.75||||||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|Medicaid|MEDICAID|17.50||||17.50||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|NON CONTRACTED|COMMERCIAL OTHER 1|17.50||||||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|17.50||||||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|UTMB|UTMB CORRECTIONAL MANAGED CARE|17.50||||||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|Tricare|TRICARE EAST REGION|||||17.50||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|17.50||||17.50||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|Medicare|MEDICARE ACUTE|||||17.50||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|Aenta Medicare Advantage|AETNA MEDICARE MA|||||17.50||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|17.50||||||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|17.50||||||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|Blue Cross HMO Specialty|BCBSTX HMO|17.50||||17.50||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|Blue Cross PPO Specialty|BCBSTX PPO|17.50||||17.50||| 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||||17.50||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|Managed Medicaid|MEDICAID SUPERIOR|17.50||||17.50||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|Cigna|CIGNA|17.50||||17.50||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|17.50||||||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|17.50||||||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|17.50||||||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|United Healthcare|UNITED HEALTHCARE|17.50||||17.50||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|United Healthcare|UNITED HEALTHCARE OTHER|17.50||||17.50||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||17.50||| 9517574|ERX|0250|OXYCODONE-ACETAM 5-325MG|United Medicare Advantage|UHC MEDICARE GOLD MA|17.50||||||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|United Medicare Advantage|UHC MEDICARE GOLD MA|||||79.50||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||79.50||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Veterans Affairs|VETERANS ADMINISTRATION|||||79.50||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Humana Medicare Advantage|HUMANA MA|79.50||||79.50||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||79.50||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||79.50||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Blue Cross PPO Specialty|BCBSTX OTHER|||||79.50||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Blue Cross PPO Specialty|BCBSTX PPO|||||79.50||| 9517582|ERX|0250|LIDOCAINE 5% PATCH|Medicare|MEDICARE ACUTE|79.50||||79.50||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.51||||||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.51||||||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.51||||||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.51||||0.51||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Medicare|MEDICARE ACUTE|0.51||||0.51||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.51||||||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|||||0.51||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|0.51||||||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|Aetna|AETNA PPO|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|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.51||||||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.51||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.51||||0.51||| 9517608|ERX|0250|CLOPIDOGREL 75MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.51||||0.51||| 9517640|ERX|0250|PHENOBARBITAL 32.4MG TABL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||||| 9517657|ERX|0250|TORSEMIDE 20MG TABLET|Medicare|MEDICARE ACUTE|15.75||||||| 9517657|ERX|0250|TORSEMIDE 20MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|15.75||||||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|7.25||||||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|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||||7.25||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|7.25||||||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.25||||||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|Managed Medicare|HEALTHSPRING MA|7.25||||||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|Medicaid|MEDICAID|7.25||||||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|7.25||||||| 9517665|ERX|0250|GUAIFENESIN 600MG TABLET|Medicare|MEDICARE ACUTE|7.25||||||| 9517673|ERX|0250|GUAIFEN-DEXTROMETH 600-30|Rusk State Hospital|RUSK STATE HOSP|0.08||||||| 9517673|ERX|0250|GUAIFEN-DEXTROMETH 600-30|Medicare|MEDICARE ACUTE|0.08||||||| 9517673|ERX|0250|GUAIFEN-DEXTROMETH 600-30|United Healthcare|UNITED HEALTHCARE|0.08||||||| 9517673|ERX|0250|GUAIFEN-DEXTROMETH 600-30|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.08||||||| 9517673|ERX|0250|GUAIFEN-DEXTROMETH 600-30|United Medicare Advantage|UHC MEDICARE GOLD MA|0.08||||||| 9517673|ERX|0250|GUAIFEN-DEXTROMETH 600-30|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.08||||||| 9517673|ERX|0250|GUAIFEN-DEXTROMETH 600-30|Veterans Affairs|VETERANS ADMINISTRATION|0.08||||||| 9517673|ERX|0250|GUAIFEN-DEXTROMETH 600-30|Workers Compensation|UT EMPLOYEE INJURY|0.08||||||| 9517673|ERX|0250|GUAIFEN-DEXTROMETH 600-30|Humana Medicare Advantage|HUMANA MA|0.08||||||| 9517673|ERX|0250|GUAIFEN-DEXTROMETH 600-30|Managed Medicaid|MEDICAID AMERIGROUP|0.08||||||| 9517673|ERX|0250|GUAIFEN-DEXTROMETH 600-30|Managed Medicaid|MEDICAID SUPERIOR|0.08||||||| 9517673|ERX|0250|GUAIFEN-DEXTROMETH 600-30|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.08||||||| 9517673|ERX|0250|GUAIFEN-DEXTROMETH 600-30|Blue Cross HMO Specialty|BCBSTX HMO|0.08||||||| 9517756|ERX|0250|DILTIAZEM XL 120MG CAPSUL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|24.50||||||| 9517756|ERX|0250|DILTIAZEM XL 120MG CAPSUL|Humana Medicare Advantage|HUMANA MA|24.50||||24.50||| 9517756|ERX|0250|DILTIAZEM XL 120MG CAPSUL|Veterans Affairs|VETERANS ADMINISTRATION|24.50||||||| 9517756|ERX|0250|DILTIAZEM XL 120MG CAPSUL|Medicare|MEDICARE ACUTE|24.50||||||| 9517764|ERX|0250|DILTIAZEM XL 180MG CAPSUL|NON CONTRACTED|COMMERCIAL OTHER 1|29.50||||||| 9517764|ERX|0250|DILTIAZEM XL 180MG CAPSUL|Medicare|MEDICARE ACUTE|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||||||| 9517798|ERX|0250|PIOGLITAZONE 15MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|46.75||||||| 9517798|ERX|0250|PIOGLITAZONE 15MG TABLET|Humana Medicare Advantage|HUMANA MA|||||46.75||| 9517798|ERX|0250|PIOGLITAZONE 15MG TABLET|Medicare|MEDICARE ACUTE|46.75||||||| 9517806|ERX|0250|LUBIPROSTONE 24MCG CAPSUL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||35.50||| 9517806|ERX|0250|LUBIPROSTONE 24MCG CAPSUL|Medicare|MEDICARE ACUTE|35.50||||35.50||| 9517806|ERX|0250|LUBIPROSTONE 24MCG CAPSUL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|35.50||||||| 9517806|ERX|0250|LUBIPROSTONE 24MCG CAPSUL|United Healthcare|UMR UNITED MEDICAL RESOURCES|35.50||||||| 9517806|ERX|0250|LUBIPROSTONE 24MCG CAPSUL|Humana Medicare Advantage|HUMANA MA|35.50||||||| 9517830|ERX|0250|LACTOBACILLUS TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.03||||||| 9517830|ERX|0250|LACTOBACILLUS TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.03||||0.03||| 9517830|ERX|0250|LACTOBACILLUS TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.03||||||| 9517830|ERX|0250|LACTOBACILLUS TABLET|Humana Medicare Advantage|HUMANA MA|0.03||||||| 9517830|ERX|0250|LACTOBACILLUS TABLET|Brinson Benefits|THE HEALTH PLAN SMITH CO|0.03||||||| 9517830|ERX|0250|LACTOBACILLUS TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.03||||||| 9517830|ERX|0250|LACTOBACILLUS TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|||||0.03||| 9517830|ERX|0250|LACTOBACILLUS TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.03||||||| 9517830|ERX|0250|LACTOBACILLUS TABLET|Medicare|MEDICARE ACUTE|0.03||||||| 9517830|ERX|0250|LACTOBACILLUS TABLET|Managed Medicare|HEALTHSPRING MA|0.03||||||| 9517830|ERX|0250|LACTOBACILLUS TABLET|Medicaid|MEDICAID|0.03||||||| 9517871|ERX|0250|AZATHIOPRINE 50MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|34.50||||||| 9517889|ERX|0250|COLESEVELAM 625MG TABLET|Medicare|MEDICARE ACUTE|0.15||||0.15||| 9517889|ERX|0250|COLESEVELAM 625MG TABLET|Humana Medicare Advantage|HUMANA MA|0.15||||||| 9517921|ERX|0250|PROPAFENONE 225MG CAPSULE|Medicare|MEDICARE ACUTE|63.25||||||| 9517947|ERX|0250|PROPAFENONE 150MG TABLET|Medicare|MEDICARE ACUTE|39.50||||||| 9518093|ERX|0250|PRIMIDONE 250MG TABLET|Medicare|MEDICARE ACUTE|30.25||||||| 9518119|ERX|0250|EZETIMIBE 10MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|34.50||||||| 9518119|ERX|0250|EZETIMIBE 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|34.50||||||| 9518119|ERX|0250|EZETIMIBE 10MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|34.50||||||| 9518119|ERX|0250|EZETIMIBE 10MG TABLET|Humana Medicare Advantage|HUMANA MA|34.50||||||| 9518119|ERX|0250|EZETIMIBE 10MG TABLET|Medicare|MEDICARE ACUTE|34.50||||34.50||| 9518150|ERX|0250|EPINEPHRINE 30MG/30ML|Blue Cross HMO Specialty|BCBSTX HMO|102.50||||||| 9518150|ERX|0250|EPINEPHRINE 30MG/30ML|Blue Cross PPO Specialty|BCBSTX PPO|||||102.50||| 9518150|ERX|0250|EPINEPHRINE 30MG/30ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|102.50||||||| 9518184|ERX|0250|RANOLAZINE 500MG TABLET|Medicare|MEDICARE ACUTE|36.75||||36.75||| 9518184|ERX|0250|RANOLAZINE 500MG TABLET|Humana Medicare Advantage|HUMANA MA|36.75||||||| 9518184|ERX|0250|RANOLAZINE 500MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|36.75||||||| 9518184|ERX|0250|RANOLAZINE 500MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|36.75||||||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|25.50||||25.50||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|United Medicare Advantage|AARP UHC WEST COMPLETE MA|25.50||||||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|Workers Compensation|WORKERS COMPENSATION OTHER|25.50||||||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|Workers Compensation|UT EMPLOYEE INJURY|25.50||||||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|Blue Cross HMO Specialty|BCBSTX HMO|25.50||||||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|25.50||||||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|Rusk State Hospital|RUSK STATE HOSP|25.50||||||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|Tricare|TRICARE EAST REGION|25.50||||||| 9518309|ERX|0250|HYDROXYCHLOROQUINE 200MG|Medicare|MEDICARE ACUTE|25.50||||||| 9518390|ERX|0250|MAGNESIUM CHLORIDE TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.03||| 9518390|ERX|0250|MAGNESIUM CHLORIDE TABLET|Medicare|MEDICARE ACUTE|0.03||||0.03||| 9518390|ERX|0250|MAGNESIUM CHLORIDE TABLET|Humana Medicare Advantage|HUMANA MA|0.03||||0.03||| 9518390|ERX|0250|MAGNESIUM CHLORIDE TABLET|Managed Medicaid|MEDICAID SUPERIOR|||||0.03||| 9518390|ERX|0250|MAGNESIUM CHLORIDE TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.03||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|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|Humana Medicare Advantage|HUMANA MA|0.05||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Medicare|MEDICARE ACUTE|0.05||||||| 9518416|ERX|0250|SENNOSIDES 8.6MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.05||||||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|NON CONTRACTED|COMMERCIAL OTHER 1|8.25||||||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|Medicare|MEDICARE ACUTE|8.25||||||| 9518424|ERX|0250|SENNOSIDES-DOCUSATE SODIU|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|8.25||||||| 9518440|ERX|0250|MEGESTROL 400MG/10ML|Humana Medicare Advantage|HUMANA MA|12.75||||||| 9518440|ERX|0250|MEGESTROL 400MG/10ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|12.75||||||| 9518440|ERX|0250|MEGESTROL 400MG/10ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12.75||||||| 9518440|ERX|0250|MEGESTROL 400MG/10ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|12.75||||||| 9518440|ERX|0250|MEGESTROL 400MG/10ML|Blue Cross HMO Specialty|BCBSTX HMO|12.75||||||| 9518440|ERX|0250|MEGESTROL 400MG/10ML|Medicaid|MEDICAID|12.75||||||| 9518440|ERX|0250|MEGESTROL 400MG/10ML|NON CONTRACTED|COMMERCIAL OTHER 1|12.75||||||| 9518440|ERX|0250|MEGESTROL 400MG/10ML|Rusk State Hospital|RUSK STATE HOSP|12.75||||||| 9518440|ERX|0250|MEGESTROL 400MG/10ML|Medicare|MEDICARE ACUTE|12.75||||||| 9518507|ERX|0250|HYOSCYAMINE SULFATE 0.125|Managed Medicaid|MEDICAID UNITED HEALTHCARE|14.50||||||| 9518663|ERX|0250|CHOLECALCIFEROL 400 UNIT|Medicare|MEDICARE ACUTE|2.50||||||| 9518663|ERX|0250|CHOLECALCIFEROL 400 UNIT|Medicaid|MEDICAID|2.50||||||| 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|United Medicare Advantage|UHC MEDICARE GOLD MA|0.10||||||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.10||||||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Veterans Affairs|VETERANS ADMINISTRATION|0.10||||||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.10||||||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Aenta Medicare Advantage|AETNA MEDICARE MA|0.10||||||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Blue Cross PPO Specialty|BCBSTX PPO|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||||0.10||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.10||||||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.10||||||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Managed Medicare|HOSPICE OF EAST TEXAS|0.10||||||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Medicaid|MEDICAID|0.10||||0.10||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Rusk State Hospital|RUSK STATE HOSP|0.10||||||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|Tricare|TRICARE EAST REGION|||||0.10||| 9518689|ERX|0250|MENTHOL-CAMP-PHEN LIPBALM|UTMB|UTMB CORRECTIONAL MANAGED CARE|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|Medicaid|MEDICAID|541.80||||||| 9518796|ERX|0250|LEVOTHYROZINE 100MCG VIAL|Humana Medicare Advantage|HUMANA MA|541.80||||||| 9518796|ERX|0250|LEVOTHYROZINE 100MCG VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|541.80||||||| 9518820|ERX|0250|RIVASTIGMINE 9.5MG PATCH|Medicare|MEDICARE ACUTE|58.50||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|United Medicare Advantage|UHC MEDICARE GOLD MA|4.75||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|United Medicare Advantage|AARP UHC WEST COMPLETE MA|4.75||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Workers Compensation|UT EMPLOYEE INJURY|4.75||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.75||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|4.75||||4.75||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Aenta Medicare Advantage|AETNA MEDICARE MA|4.75||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Blue Cross HMO Specialty|BCBSTX HMO|4.75||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Aetna|AETNA PPO|4.75||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Blue Cross PPO Specialty|BCBSTX PPO|4.75||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Humana Medicare Advantage|HUMANA MA|4.75||||4.75||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.75||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|4.75||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Medicaid|MEDICAID|4.75||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|NON CONTRACTED|COMMERCIAL OTHER 1|4.75||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Rusk State Hospital|RUSK STATE HOSP|4.75||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|UTMB|UTMB CORRECTIONAL MANAGED CARE|4.75||||||| 9518903|ERX|0250|K-NA PHOS 280-160-250MG P|Medicare|MEDICARE ACUTE|4.75||||4.75||| 9518952|ERX|0250|COENZYME Q10 100MG CAPSUL|Humana Medicare Advantage|HUMANA MA|||||4.50||| 9518952|ERX|0250|COENZYME Q10 100MG CAPSUL|Blue Cross PPO Specialty|BCBSTX OTHER|4.50||||||| 9518952|ERX|0250|COENZYME Q10 100MG CAPSUL|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|4.50||||||| 9518986|ERX|0258|EMPTY CONTAINER 500ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.79||||||| 9519018|ERX|0250|FERROUS GLUCONATE 325MG T|Humana Medicare Advantage|HUMANA MA|2.50||||||| 9519018|ERX|0250|FERROUS GLUCONATE 325MG T|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.50||||||| 9519018|ERX|0250|FERROUS GLUCONATE 325MG T|Medicare|MEDICARE ACUTE|2.50||||||| 9519034|ERX|0258|CLINIMIX E 5/20 2000ML|Humana Medicare Advantage|HUMANA MA|444.25||||||| 9519075|ERX|0250|LACTOBACILLUS GRANULES 1|Medicare|MEDICARE ACUTE|12.25||||||| 9519133|ERX|0250|DOCUSATE SODIUM 100MG/10M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.06||||||| 9519133|ERX|0250|DOCUSATE SODIUM 100MG/10M|Medicare|MEDICARE ACUTE|0.06||||||| 9519141|ERX|0250|SUCRALFATE 1 G/10ML|Medicare|MEDICARE ACUTE|0.27||||||| 9519141|ERX|0250|SUCRALFATE 1 G/10ML|United Medicare Advantage|UHC MEDICARE GOLD MA|0.27||||||| 9519141|ERX|0250|SUCRALFATE 1 G/10ML|Humana Medicare Advantage|HUMANA MA|0.27||||||| 9519190|ERX|0250|CEFTRIAXONE 1GM/100ML NS|Aenta Medicare Advantage|AETNA MEDICARE MA|236.75||||236.75||| 9519190|ERX|0250|CEFTRIAXONE 1GM/100ML NS|Blue Cross HMO Specialty|BCBSTX HMO|236.75||||236.75||| 9519190|ERX|0250|CEFTRIAXONE 1GM/100ML NS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||236.75||| 9519190|ERX|0250|CEFTRIAXONE 1GM/100ML NS|Aetna|AETNA OTHER|236.75||||||| 9519190|ERX|0250|CEFTRIAXONE 1GM/100ML NS|Blue Cross PPO Specialty|BCBSTX OTHER|||||236.75||| 9519190|ERX|0250|CEFTRIAXONE 1GM/100ML NS|Blue Cross PPO Specialty|BCBSTX PPO|236.75||||236.75||| 9519190|ERX|0250|CEFTRIAXONE 1GM/100ML NS|Humana Medicare Advantage|HUMANA MA|236.75||||236.75||| 9519190|ERX|0250|CEFTRIAXONE 1GM/100ML NS|Cigna|CIGNA|||||236.75||| 9519190|ERX|0250|CEFTRIAXONE 1GM/100ML NS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||236.75||| 9519190|ERX|0250|CEFTRIAXONE 1GM/100ML NS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|236.75||||236.75||| 9519190|ERX|0250|CEFTRIAXONE 1GM/100ML NS|Managed Medicaid|MEDICAID AMERIGROUP|236.75||||236.75||| 9519190|ERX|0250|CEFTRIAXONE 1GM/100ML NS|Managed Medicaid|MEDICAID SUPERIOR|236.75||||236.75||| 9519190|ERX|0250|CEFTRIAXONE 1GM/100ML NS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|236.75||||236.75||| 9519190|ERX|0250|CEFTRIAXONE 1GM/100ML NS|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||236.75||| 9519190|ERX|0250|CEFTRIAXONE 1GM/100ML NS|United Medicare Advantage|UHC MEDICARE GOLD MA|236.75||||236.75||| 9519190|ERX|0250|CEFTRIAXONE 1GM/100ML NS|United Healthcare|UNITED HEALTHCARE|||||236.75||| 9519190|ERX|0250|CEFTRIAXONE 1GM/100ML NS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|236.75||||236.75||| 9519190|ERX|0250|CEFTRIAXONE 1GM/100ML NS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|236.75||||236.75||| 9519190|ERX|0250|CEFTRIAXONE 1GM/100ML NS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|236.75||||236.75||| 9519190|ERX|0250|CEFTRIAXONE 1GM/100ML NS|United Healthcare|UNITED HEALTHCARE OTHER|||||236.75||| 9519190|ERX|0250|CEFTRIAXONE 1GM/100ML NS|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|236.75||||||| 9519190|ERX|0250|CEFTRIAXONE 1GM/100ML NS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|236.75||||236.75||| 9519190|ERX|0250|CEFTRIAXONE 1GM/100ML NS|Medicaid|SUPERIOR HEALTHPLAN CHIP|236.75||||||| 9519190|ERX|0250|CEFTRIAXONE 1GM/100ML NS|Medicaid|MEDICAID|236.75||||236.75||| 9519190|ERX|0250|CEFTRIAXONE 1GM/100ML NS|NON CONTRACTED|COMMERCIAL OTHER 1|||||236.75||| 9519190|ERX|0250|CEFTRIAXONE 1GM/100ML NS|UTMB|UTMB CORRECTIONAL MANAGED CARE|236.75||||236.75||| 9519190|ERX|0250|CEFTRIAXONE 1GM/100ML NS|Rusk State Hospital|RUSK STATE HOSP|||||236.75||| 9519190|ERX|0250|CEFTRIAXONE 1GM/100ML NS|Tricare|TRICARE EAST REGION|||||236.75||| 9519190|ERX|0250|CEFTRIAXONE 1GM/100ML NS|Medicare|MEDICARE ACUTE|236.75||||236.75||| 9519208|ERX|0250|CEFTRIAXONE 2 GM/100ML NS|Medicare|MEDICARE ACUTE|297.50||||||| 9519208|ERX|0250|CEFTRIAXONE 2 GM/100ML NS|Managed Medicare|HEALTHSPRING MA|297.50||||||| 9519208|ERX|0250|CEFTRIAXONE 2 GM/100ML NS|Humana Medicare Advantage|HUMANA MA|297.50||||||| 9519208|ERX|0250|CEFTRIAXONE 2 GM/100ML NS|Managed Medicaid|MEDICAID SUPERIOR|297.50||||297.50||| 9519208|ERX|0250|CEFTRIAXONE 2 GM/100ML NS|Aenta Medicare Advantage|AETNA MEDICARE MA|297.50||||||| 9519208|ERX|0250|CEFTRIAXONE 2 GM/100ML NS|Blue Cross PPO Specialty|BCBSTX PPO|297.50||||||| 9519216|ERX|0250|CEFEPIME 1 GM/100ML NS MB|United Medicare Advantage|AARP UHC WEST COMPLETE MA|2.46||||2.46||| 9519216|ERX|0250|CEFEPIME 1 GM/100ML NS MB|United Medicare Advantage|UHC MEDICARE GOLD MA|2.46||||2.46||| 9519216|ERX|0250|CEFEPIME 1 GM/100ML NS MB|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.46||||2.46||| 9519216|ERX|0250|CEFEPIME 1 GM/100ML NS MB|United Healthcare|UNITED HEALTHCARE|||||2.46||| 9519216|ERX|0250|CEFEPIME 1 GM/100ML NS MB|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||2.46||| 9519216|ERX|0250|CEFEPIME 1 GM/100ML NS MB|Blue Cross PPO Specialty|BCBSTX PPO|2.46||||2.46||| 9519216|ERX|0250|CEFEPIME 1 GM/100ML NS MB|Aenta Medicare Advantage|AETNA MEDICARE MA|2.46||||2.46||| 9519216|ERX|0250|CEFEPIME 1 GM/100ML NS MB|Blue Cross HMO Specialty|BCBSTX HMO|2.46||||2.46||| 9519216|ERX|0250|CEFEPIME 1 GM/100ML NS MB|Blue Cross PPO Specialty|BCBSTX OTHER|2.46||||2.46||| 9519216|ERX|0250|CEFEPIME 1 GM/100ML NS MB|Humana Medicare Advantage|HUMANA MA|2.46||||2.46||| 9519216|ERX|0250|CEFEPIME 1 GM/100ML NS MB|Cigna|CIGNA|||||2.46||| 9519216|ERX|0250|CEFEPIME 1 GM/100ML NS MB|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.46||||2.46||| 9519216|ERX|0250|CEFEPIME 1 GM/100ML NS MB|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.46||||2.46||| 9519216|ERX|0250|CEFEPIME 1 GM/100ML NS MB|Managed Medicaid|MEDICAID SUPERIOR|2.46||||2.46||| 9519216|ERX|0250|CEFEPIME 1 GM/100ML NS MB|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.46||||2.46||| 9519216|ERX|0250|CEFEPIME 1 GM/100ML NS MB|Veterans Affairs|VETERANS ADMINISTRATION|2.46||||2.46||| 9519216|ERX|0250|CEFEPIME 1 GM/100ML NS MB|Managed Medicaid|MEDICAID AMERIGROUP|2.46||||2.46||| 9519216|ERX|0250|CEFEPIME 1 GM/100ML NS MB|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||2.46||| 9519216|ERX|0250|CEFEPIME 1 GM/100ML NS MB|Medicaid|MEDICAID TEXAS CHILDRENS|||||2.46||| 9519216|ERX|0250|CEFEPIME 1 GM/100ML NS MB|Medicaid|MEDICAID|2.46||||||| 9519216|ERX|0250|CEFEPIME 1 GM/100ML NS MB|Medicaid|COUNTY INDIGENT HEALTH OTHER|2.46||||||| 9519216|ERX|0250|CEFEPIME 1 GM/100ML NS MB|NON CONTRACTED|COMMERCIAL OTHER 1|2.46||||||| 9519216|ERX|0250|CEFEPIME 1 GM/100ML NS MB|Tricare|TRICARE EAST REGION|||||2.46||| 9519216|ERX|0250|CEFEPIME 1 GM/100ML NS MB|Rusk State Hospital|RUSK STATE HOSP|2.46||||2.46||| 9519216|ERX|0250|CEFEPIME 1 GM/100ML NS MB|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.46||||2.46||| 9519216|ERX|0250|CEFEPIME 1 GM/100ML NS MB|Medicare|MEDICARE ACUTE|2.46||||2.46||| 9519224|ERX|0250|CEFEPIME 2 GM/100ML NS MB|Rusk State Hospital|RUSK STATE HOSP|410.50||||410.50||| 9519224|ERX|0250|CEFEPIME 2 GM/100ML NS MB|UTMB|UTMB CORRECTIONAL MANAGED CARE|410.50||||||| 9519224|ERX|0250|CEFEPIME 2 GM/100ML NS MB|Medicare|MEDICARE ACUTE|410.50||||410.50||| 9519224|ERX|0250|CEFEPIME 2 GM/100ML NS MB|Medicaid|COUNTY INDIGENT HEALTH OTHER|410.50||||||| 9519224|ERX|0250|CEFEPIME 2 GM/100ML NS MB|Managed Medicare|HEALTHSPRING MA|410.50||||||| 9519224|ERX|0250|CEFEPIME 2 GM/100ML NS MB|Humana Medicare Advantage|HUMANA MA|410.50||||410.50||| 9519224|ERX|0250|CEFEPIME 2 GM/100ML NS MB|Managed Medicaid|MEDICAID UNITED HEALTHCARE|410.50||||||| 9519224|ERX|0250|CEFEPIME 2 GM/100ML NS MB|Aenta Medicare Advantage|AETNA MEDICARE MA|410.50||||||| 9519224|ERX|0250|CEFEPIME 2 GM/100ML NS MB|Blue Cross HMO Specialty|BCBSTX HMO|410.50||||410.50||| 9519224|ERX|0250|CEFEPIME 2 GM/100ML NS MB|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|410.50||||||| 9519224|ERX|0250|CEFEPIME 2 GM/100ML NS MB|Aetna|AETNA PPO|410.50||||||| 9519224|ERX|0250|CEFEPIME 2 GM/100ML NS MB|NON CONTRACTED|COMMERCIAL OTHER 1|410.50||||||| 9519224|ERX|0250|CEFEPIME 2 GM/100ML NS MB|Blue Cross PPO Specialty|BCBSTX OTHER|410.50||||||| 9519224|ERX|0250|CEFEPIME 2 GM/100ML NS MB|Blue Cross PPO Specialty|BCBSTX PPO|410.50||||||| 9519224|ERX|0250|CEFEPIME 2 GM/100ML NS MB|United Medicare Advantage|AARP UHC WEST COMPLETE MA|410.50||||||| 9519224|ERX|0250|CEFEPIME 2 GM/100ML NS MB|United Healthcare|UNITED HEALTHCARE|410.50||||||| 9519224|ERX|0250|CEFEPIME 2 GM/100ML NS MB|United Medicare Advantage|UHC MEDICARE GOLD MA|410.50||||410.50||| 9519224|ERX|0250|CEFEPIME 2 GM/100ML NS MB|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|410.50||||410.50||| 9519224|ERX|0250|CEFEPIME 2 GM/100ML NS MB|Workers Compensation|UT EMPLOYEE INJURY|410.50||||||| 9519224|ERX|0250|CEFEPIME 2 GM/100ML NS MB|Workers Compensation|WORKERS COMPENSATION OTHER|410.50||||410.50||| 9519232|ERX|0250|CEFOXITIN 1 GM/100ML NS M|Veterans Affairs|VETERANS ADMINISTRATION|130.25||||||| 9519232|ERX|0250|CEFOXITIN 1 GM/100ML NS M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|130.25||||||| 9519232|ERX|0250|CEFOXITIN 1 GM/100ML NS M|United Medicare Advantage|AARP UHC WEST COMPLETE MA|130.25||||||| 9519232|ERX|0250|CEFOXITIN 1 GM/100ML NS M|United Medicare Advantage|UHC MEDICARE GOLD MA|130.25||||||| 9519232|ERX|0250|CEFOXITIN 1 GM/100ML NS M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|130.25||||||| 9519232|ERX|0250|CEFOXITIN 1 GM/100ML NS M|Aenta Medicare Advantage|AETNA MEDICARE MA|130.25||||||| 9519232|ERX|0250|CEFOXITIN 1 GM/100ML NS M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|130.25||||||| 9519232|ERX|0250|CEFOXITIN 1 GM/100ML NS M|Humana Medicare Advantage|HUMANA MA|130.25||||||| 9519232|ERX|0250|CEFOXITIN 1 GM/100ML NS M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|130.25||||||| 9519232|ERX|0250|CEFOXITIN 1 GM/100ML NS M|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|130.25||||||| 9519232|ERX|0250|CEFOXITIN 1 GM/100ML NS M|Managed Medicaid|MEDICAID SUPERIOR|||||130.25||| 9519232|ERX|0250|CEFOXITIN 1 GM/100ML NS M|Managed Medicare|HEALTHSPRING MA|130.25||||||| 9519232|ERX|0250|CEFOXITIN 1 GM/100ML NS M|Medicare|MEDICARE ACUTE|130.25||||130.25||| 9519240|ERX|0250|CEFOXITIN 2 GM/100ML NS M|NON CONTRACTED|COMMERCIAL OTHER 1|160.50||||||| 9519240|ERX|0250|CEFOXITIN 2 GM/100ML NS M|Tricare|TRICARE EAST REGION|||||160.50||| 9519240|ERX|0250|CEFOXITIN 2 GM/100ML NS M|Medicare|MEDICARE ACUTE|160.50||||160.50||| 9519240|ERX|0250|CEFOXITIN 2 GM/100ML NS M|Managed Medicare|HEALTHSPRING MA|160.50||||||| 9519240|ERX|0250|CEFOXITIN 2 GM/100ML NS M|Medicaid|MEDICAID|160.50||||160.50||| 9519240|ERX|0250|CEFOXITIN 2 GM/100ML NS M|Humana Medicare Advantage|HUMANA MA|160.50||||160.50||| 9519240|ERX|0250|CEFOXITIN 2 GM/100ML NS M|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|160.50||||||| 9519240|ERX|0250|CEFOXITIN 2 GM/100ML NS M|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||160.50||| 9519240|ERX|0250|CEFOXITIN 2 GM/100ML NS M|Managed Medicaid|MEDICAID SUPERIOR|160.50||||160.50||| 9519240|ERX|0250|CEFOXITIN 2 GM/100ML NS M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|160.50||||160.50||| 9519240|ERX|0250|CEFOXITIN 2 GM/100ML NS M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|160.50||||160.50||| 9519240|ERX|0250|CEFOXITIN 2 GM/100ML NS M|Managed Medicaid|MEDICAID AMERIGROUP|160.50||||160.50||| 9519240|ERX|0250|CEFOXITIN 2 GM/100ML NS M|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|160.50||||||| 9519240|ERX|0250|CEFOXITIN 2 GM/100ML NS M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|160.50||||160.50||| 9519240|ERX|0250|CEFOXITIN 2 GM/100ML NS M|Blue Cross PPO Specialty|BCBSTX PPO|160.50||||160.50||| 9519240|ERX|0250|CEFOXITIN 2 GM/100ML NS M|Aenta Medicare Advantage|AETNA MEDICARE MA|160.50||||||| 9519240|ERX|0250|CEFOXITIN 2 GM/100ML NS M|Blue Cross HMO Specialty|BCBSTX HMO|||||160.50||| 9519240|ERX|0250|CEFOXITIN 2 GM/100ML NS M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|160.50||||160.50||| 9519240|ERX|0250|CEFOXITIN 2 GM/100ML NS M|Veterans Affairs|VETERANS ADMINISTRATION|160.50||||||| 9519240|ERX|0250|CEFOXITIN 2 GM/100ML NS M|United Medicare Advantage|UHC MEDICARE GOLD MA|160.50||||160.50||| 9519240|ERX|0250|CEFOXITIN 2 GM/100ML NS M|United Healthcare|UNITED HEALTHCARE|160.50||||160.50||| 9519240|ERX|0250|CEFOXITIN 2 GM/100ML NS M|United Healthcare|UNITED HEALTHCARE OTHER|160.50||||||| 9519240|ERX|0250|CEFOXITIN 2 GM/100ML NS M|United Medicare Advantage|AARP UHC WEST COMPLETE MA|160.50||||||| 9519240|ERX|0250|CEFOXITIN 2 GM/100ML NS M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|160.50||||||| 9519273|ERX|0250|AMPICILLIN 1 GM NS MB+ 10|United Healthcare|UNITED HEALTHCARE OTHER|1.14||||||| 9519273|ERX|0250|AMPICILLIN 1 GM NS MB+ 10|United Healthcare|UNITED HEALTHCARE|1.14||||||| 9519273|ERX|0250|AMPICILLIN 1 GM NS MB+ 10|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1.14||||||| 9519273|ERX|0250|AMPICILLIN 1 GM NS MB+ 10|Blue Cross PPO Specialty|BCBSTX PPO|1.14||||||| 9519273|ERX|0250|AMPICILLIN 1 GM NS MB+ 10|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.14||||||| 9519273|ERX|0250|AMPICILLIN 1 GM NS MB+ 10|Managed Medicaid|MEDICAID UNITED HEALTHCARE|1.14||||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|Managed Medicaid|MEDICAID AMERIGROUP|1.14||||1.14||| 9519273|ERX|0250|AMPICILLIN 1 GM NS MB+ 10|Medicaid|MEDICAID|1.14||||||| 9519281|ERX|0250|AMPICILLIN 2 GM NS MB+ 10|NON CONTRACTED|COMMERCIAL OTHER 2|2.08||||||| 9519281|ERX|0250|AMPICILLIN 2 GM NS MB+ 10|Medicaid|MEDICAID|2.08||||||| 9519281|ERX|0250|AMPICILLIN 2 GM NS MB+ 10|Managed Medicaid|MEDICAID AMERIGROUP|2.08||||2.08||| 9519281|ERX|0250|AMPICILLIN 2 GM NS MB+ 10|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|2.08||||||| 9519281|ERX|0250|AMPICILLIN 2 GM NS MB+ 10|Managed Medicaid|MEDICAID SUPERIOR|2.08||||2.08||| 9519281|ERX|0250|AMPICILLIN 2 GM NS MB+ 10|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.08||||2.08||| 9519281|ERX|0250|AMPICILLIN 2 GM NS MB+ 10|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.08||||||| 9519281|ERX|0250|AMPICILLIN 2 GM NS MB+ 10|Blue Cross HMO Specialty|BCBSTX HMO|2.08||||||| 9519281|ERX|0250|AMPICILLIN 2 GM NS MB+ 10|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.08||||||| 9519281|ERX|0250|AMPICILLIN 2 GM NS MB+ 10|Blue Cross PPO Specialty|BCBSTX PPO|2.08||||2.08||| 9519281|ERX|0250|AMPICILLIN 2 GM NS MB+ 10|United Healthcare|UNITED HEALTHCARE OTHER|2.08||||||| 9519281|ERX|0250|AMPICILLIN 2 GM NS MB+ 10|United Healthcare|UNITED HEALTHCARE|2.08||||2.08||| 9519307|ERX|0250||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|610.25||||||| 9519307|ERX|0250||Humana Medicare Advantage|HUMANA MA|||||610.25||| 9519323|ERX|0250|SPIRONOLACTONE 50MG TABLE|Medicare|MEDICARE ACUTE|0.21||||||| 9519323|ERX|0250|SPIRONOLACTONE 50MG TABLE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.21||||||| 9519323|ERX|0250|SPIRONOLACTONE 50MG TABLE|Humana Medicare Advantage|HUMANA MA|0.21||||0.21||| 9519323|ERX|0250|SPIRONOLACTONE 50MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.21||||||| 9519323|ERX|0250|SPIRONOLACTONE 50MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.21||||||| 9519323|ERX|0250|SPIRONOLACTONE 50MG TABLE|Blue Cross HMO Specialty|BCBSTX HMO|0.21||||0.21||| 9519331|ERX|0250|MEROPENEM 1 GM/100ML MB+|Aenta Medicare Advantage|AETNA MEDICARE MA|682.50||||682.50||| 9519331|ERX|0250|MEROPENEM 1 GM/100ML MB+|Blue Cross PPO Specialty|BCBSTX PPO|682.50||||||| 9519331|ERX|0250|MEROPENEM 1 GM/100ML MB+|Humana Medicare Advantage|HUMANA MA|682.50||||||| 9519331|ERX|0250|MEROPENEM 1 GM/100ML MB+|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|682.50||||682.50||| 9519331|ERX|0250|MEROPENEM 1 GM/100ML MB+|Veterans Affairs|VETERANS ADMINISTRATION|682.50||||||| 9519331|ERX|0250|MEROPENEM 1 GM/100ML MB+|United Medicare Advantage|UHC MEDICARE GOLD MA|682.50||||||| 9519331|ERX|0250|MEROPENEM 1 GM/100ML MB+|Workers Compensation|WORKERS COMPENSATION OTHER|682.50||||||| 9519331|ERX|0250|MEROPENEM 1 GM/100ML MB+|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|682.50||||||| 9519331|ERX|0250|MEROPENEM 1 GM/100ML MB+|UTMB|UTMB CORRECTIONAL MANAGED CARE|682.50||||||| 9519331|ERX|0250|MEROPENEM 1 GM/100ML MB+|Medicare|MEDICARE ACUTE|682.50||||682.50||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|Medicare|MEDICARE ACUTE|3.79||||||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|Medicaid|MEDICAID|3.79||||||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|Veterans Affairs|VETERANS ADMINISTRATION|3.79||||||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|Humana Medicare Advantage|HUMANA MA|3.79||||||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.79||||||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.79||||||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|Aenta Medicare Advantage|AETNA MEDICARE MA|3.79||||||| 9519349|ERX|0250|MEROPENEM 500MG/100ML MB+|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.79||||||| 9519372|ERX|0250|AMPICILL-SULBAC 1.5G/100|United Medicare Advantage|AARP UHC WEST COMPLETE MA|1.14||||||| 9519372|ERX|0250|AMPICILL-SULBAC 1.5G/100|Medicare|MEDICARE ACUTE|1.14||||||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|Medicare|MEDICARE ACUTE|1.92||||1.92||| 9519380|ERX|0250|AMPICILLIN-SULBAC 3G/100M|Humana Medicare Advantage|HUMANA MA|1.92||||||| 9519455|ERX|0250|DRONEDARONE 400MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.31||||||| 9519455|ERX|0250|DRONEDARONE 400MG TABLET|Humana Medicare Advantage|HUMANA MA|0.31||||||| 9519455|ERX|0250|DRONEDARONE 400MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.31||||||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.06||||||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.06||||||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Medicare|MEDICARE ACUTE|0.06||||0.06||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|United Medicare Advantage|UHC MEDICARE GOLD MA|0.06||||||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Workers Compensation|WORKERS COMPENSATION OTHER|0.06||||||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Humana Medicare Advantage|HUMANA MA|0.06||||||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Managed Medicaid|MEDICAID SUPERIOR|0.06||||||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.06||||||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.06||||||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Blue Cross HMO Specialty|BCBSTX HMO|0.06||||||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Aetna|AETNA OTHER|0.06||||||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Blue Cross PPO Specialty|BCBSTX PPO|0.06||||||| 9519471|ERX|0250|HYDROCHLOROTHIAZIDE 12.5M|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.06||| 9519489|ERX|0250|VANCOMYCIN 1 GM/250ML D5W|Humana Medicare Advantage|HUMANA MA|194.50||||||| 9519489|ERX|0250|VANCOMYCIN 1 GM/250ML D5W|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||194.50||| 9519489|ERX|0250|VANCOMYCIN 1 GM/250ML D5W|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|194.50||||||| 9519505|ERX|0250|FLUCONAZOLE 100MG IN NS 5|Medicare|MEDICARE ACUTE|113.50||||||| 9519505|ERX|0250|FLUCONAZOLE 100MG IN NS 5|Humana Medicare Advantage|HUMANA MA|113.50||||||| 9519513|ERX|0250|NICARDIPINE 20MG/200MLSAL|Humana Medicare Advantage|HUMANA MA|798.75||||798.75||| 9519513|ERX|0250|NICARDIPINE 20MG/200MLSAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||798.75||| 9519513|ERX|0250|NICARDIPINE 20MG/200MLSAL|Medicare|MEDICARE ACUTE|||||798.75||| 9519729|ERX|0250|DESVENLAFAXINE 50MG TABLE|Medicare|MEDICARE ACUTE|45.50||||||| 9519729|ERX|0250|DESVENLAFAXINE 50MG TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|45.50||||||| 9519729|ERX|0250|DESVENLAFAXINE 50MG TABLE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|45.50||||||| 9519729|ERX|0250|DESVENLAFAXINE 50MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||45.50||| 9519737|ERX|0250|QUETIAPINE XR 200MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||80.50||| 9519737|ERX|0250|QUETIAPINE XR 200MG TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|80.50||||||| 9519752|ERX|0250|MISOPROSTOL 100MCG TABLET|Medicaid|MEDICAID|16.50||||||| 9519752|ERX|0250|MISOPROSTOL 100MCG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|16.50||||||| 9519752|ERX|0250|MISOPROSTOL 100MCG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|16.50||||||| 9519752|ERX|0250|MISOPROSTOL 100MCG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|16.50||||||| 9519752|ERX|0250|MISOPROSTOL 100MCG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|16.50||||16.50||| 9519752|ERX|0250|MISOPROSTOL 100MCG TABLET|Managed Medicaid|MEDICAID SUPERIOR|16.50||||||| 9519869|ERX|0250|PRASUGREL 10MG TABLET|Humana Medicare Advantage|HUMANA MA|46.50||||||| 9519885|ERX|0250|CETIRIZINE SYRUP 30MG/30M|Medicaid|MEDICAID|||||25.50||| 9519885|ERX|0250|CETIRIZINE SYRUP 30MG/30M|Managed Medicaid|MEDICAID AMERIGROUP|25.50||||25.50||| 9519885|ERX|0250|CETIRIZINE SYRUP 30MG/30M|Managed Medicaid|MEDICAID SUPERIOR|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|Humana Medicare Advantage|HUMANA MA|25.50||||25.50||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|NON CONTRACTED|COMMERCIAL OTHER 1|12.75||||||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|Rusk State Hospital|RUSK STATE HOSP|12.75||||||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|UTMB|UTMB CORRECTIONAL MANAGED CARE|12.75||||||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|Medicare|MEDICARE ACUTE|12.75||||12.75||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12.75||||12.75||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|Blue Cross HMO Specialty|BCBSTX HMO|12.75||||||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|Aetna|AETNA PPO|12.75||||12.75||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|Blue Cross PPO Specialty|BCBSTX PPO|12.75||||12.75||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|Humana Medicare Advantage|HUMANA MA|12.75||||||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|United Healthcare|UNITED HEALTHCARE|12.75||||||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|United Medicare Advantage|UHC MEDICARE GOLD MA|12.75||||||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|Workers Compensation|UT EMPLOYEE INJURY|12.75||||||| 9520016|ERX|0250|CHOLECALCIFEROL 5000 UNIT|United Medicare Advantage|AARP UHC WEST COMPLETE MA|12.75||||||| 9520248|ERX|0250|BRIMONIDINE 0.1% EYE DROP|Medicare|MEDICARE ACUTE|529.50||||||| 9520255|ERX|0250|VERAPAMIL SR 240MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|30.25||||||| 9520255|ERX|0250|VERAPAMIL SR 240MG TABLET|Medicare|MEDICARE ACUTE|30.25||||||| 9520479|ERX|0250|NORMAL SALINE SOLUTION, 1|Medicaid|MEDICAID|12.50||||||| 9520479|ERX|0250|NORMAL SALINE SOLUTION, 1|Managed Medicaid|MEDICAID SUPERIOR|12.50||||||| 9520479|ERX|0250|NORMAL SALINE SOLUTION, 1|Managed Medicaid|MEDICAID AMERIGROUP|12.50||||||| 9520479|ERX|0250|NORMAL SALINE SOLUTION, 1|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||12.50||| 9520578|ERX|0250|NITROGLYCERIN 25MG/250ML|Humana Medicare Advantage|HUMANA MA|111.25||||||| 9520578|ERX|0250|NITROGLYCERIN 25MG/250ML|Medicare|MEDICARE ACUTE|111.25||||||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Managed Medicare|BCBS MEDICARE PPO MA|||||18.75||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Medicaid|MEDICAID|||||18.75||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||18.75||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Tricare|TRICARE EAST REGION|18.75||||||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Medicare|MEDICARE ACUTE|18.75||||18.75||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Veterans Affairs|VETERANS ADMINISTRATION|||||18.75||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|18.75||||||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||18.75||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|United Healthcare|UNITED HEALTHCARE OTHER|||||18.75||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|United Healthcare|UNITED HEALTHCARE|||||18.75||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|18.75||||||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Workers Compensation|WORKERS COMPENSATION OTHER|||||18.75||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|18.75||||18.75||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||18.75||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Blue Cross PPO Specialty|BCBSTX PPO|18.75||||18.75||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Blue Cross HMO Specialty|BCBSTX HMO|18.75||||18.75||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Humana Medicare Advantage|HUMANA MA|18.75||||18.75||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|18.75||||||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||18.75||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|18.75||||||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Managed Medicaid|MEDICAID SUPERIOR|||||18.75||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|18.75||||||| 9520602|ERX|0250|LIDOCAINE PF 2%, 5ML|Managed Medicaid|MEDICAID AMERIGROUP|||||18.75||| 9520719|ERX|0250|LACOSAMIDE 100MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|49.25||||||| 9520719|ERX|0250|LACOSAMIDE 100MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|49.25||||||| 9520834|ERX|0250|DABIGATRAN 75MG CAPSULE|Medicare|MEDICARE ACUTE|0.37||||||| 9520834|ERX|0250|DABIGATRAN 75MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|0.37||||||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Veterans Affairs|VETERANS ADMINISTRATION|98.25||||98.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP 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|Workers Compensation|WORKERS COMPENSATION OTHER|98.25||||98.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|United Healthcare|UNITED HEALTHCARE OTHER|||||98.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|United Healthcare|UNITED HEALTHCARE|||||98.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Humana Medicare Advantage|HUMANA MA|98.25||||98.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Cigna|CIGNA|||||98.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Cigna|CIGNA|98.25||||98.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|98.25||||||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|98.25||||98.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Managed Medicaid|MEDICAID AMERIGROUP|||||98.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Managed Medicaid|MEDICAID SUPERIOR|98.25||||98.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||98.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|98.25||||||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|98.25||||98.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Blue Cross PPO Specialty|BCBSTX OTHER|||||98.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Aenta Medicare Advantage|AETNA MEDICARE MA|98.25||||98.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Blue Cross HMO Specialty|BCBSTX HMO|98.25||||98.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|United Healthcare|UNITED HEALTHCARE|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|Blue Cross PPO Specialty|BCBSTX PPO|98.25||||98.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Managed Medicare|HEALTHSPRING MA|98.25||||98.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Medicaid|MEDICAID|98.25||||98.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|NON CONTRACTED|COMMERCIAL OTHER 1|98.25||||98.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||98.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Tricare|TRICARE EAST REGION|98.25||||||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||98.25||| 9520875|ERX|0250|ACETAMINOPHEN INJ 100ML B|Medicare|MEDICARE ACUTE|98.25||||98.25||| 9520909|ERX|0250|RIFAXIMIN 550MG TABLET|Medicare|MEDICARE ACUTE|152.25||||||| 9520909|ERX|0250|RIFAXIMIN 550MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|||||152.25||| 9520909|ERX|0250|RIFAXIMIN 550MG TABLET|Humana Medicare Advantage|HUMANA MA|152.25||||||| 9520909|ERX|0250|RIFAXIMIN 550MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|152.25||||||| 9520909|ERX|0250|RIFAXIMIN 550MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|152.25||||||| 9521089|ERX|0250|METRONIDAZOLE IN NACL (IS|Medicaid|MOLINA HEALTHCARE OF TEXAS|58.50||||||| 9521154|ERX|0250|MUPIROCIN 2% OINT, 22 GM|Managed Medicaid|MEDICAID AMERIGROUP|||||6.69||| 9521154|ERX|0250|MUPIROCIN 2% OINT, 22 GM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|6.69||||||| 9521154|ERX|0250|MUPIROCIN 2% OINT, 22 GM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|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|UTMB|UTMB CORRECTIONAL MANAGED CARE|6.69||||||| 9521154|ERX|0250|MUPIROCIN 2% OINT, 22 GM|Medicare|MEDICARE ACUTE|6.69||||||| 9521253|ERX|0250|PAROXETINE 20MG TABLET|Medicare|MEDICARE PART B ONLY IP|39.25||||||| 9521253|ERX|0250|PAROXETINE 20MG TABLET|Medicare|MEDICARE ACUTE|39.25||||||| 9521253|ERX|0250|PAROXETINE 20MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|39.25||||||| 9521253|ERX|0250|PAROXETINE 20MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|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||||39.25||| 9521311|ERX|0250|AMOX-CLAV 500-125MG TABLE|Medicare|MEDICARE ACUTE|61.25||||||| 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 AMERIGROUP|||||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||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|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|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||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|United Medicare Advantage|UHC MEDICARE GOLD MA|||||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|NON CONTRACTED|COMMERCIAL OTHER 1|||||83.75||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|Tricare|TRICARE EAST REGION|||||83.75||| 9521329|ERX|0250|AMOX-CLAV 875-125MG TABLE|Medicare|MEDICARE ACUTE|83.75||||||| 9521451|ERX|0250|AZELASTINE NASAL SPRAY, 3|Medicare|MEDICARE ACUTE|935.25||||935.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|Veterans Affairs|VETERANS ADMINISTRATION|||||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|Blue Cross HMO Specialty|BCBSTX HMO|||||99.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|Blue Cross PPO Specialty|BCBSTX PPO|||||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 UNITED HEALTHCARE|||||99.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|Managed Medicaid|MEDICAID AMERIGROUP|||||99.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|NON CONTRACTED|COMMERCIAL OTHER 1|||||99.25||| 9521501|ERX|0250|TRIAMCINOLONE 40MG/ML, 1M|Medicare|MEDICARE ACUTE|99.25||||99.25||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|565.25||||||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|Managed Medicaid|MEDICAID SUPERIOR|565.25||||||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|565.25||||||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|Medicaid|MEDICAID|565.25||||||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|Medicare|MEDICARE ACUTE|565.25||||||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|Humana Medicare Advantage|HUMANA MA|565.25||||565.25||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|Aenta Medicare Advantage|AETNA MEDICARE MA|565.25||||||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|Blue Cross HMO Specialty|BCBSTX HMO|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 PPO Specialty|BCBSTX OTHER|||||565.25||| 9521543|ERX|0258|LEVOFLOXACIN 750MG/150ML|United Medicare Advantage|UHC MEDICARE GOLD 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|United Medicare Advantage|AARP UHC WEST COMPLETE MA|565.25||||||| 9521550|ERX|0250|LEVOFLOXACIN 250MG/50ML D|Aenta Medicare Advantage|AETNA MEDICARE MA|252.25||||||| 9521550|ERX|0250|LEVOFLOXACIN 250MG/50ML D|Medicare|MEDICARE ACUTE|252.25||||||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Managed Medicare|HEALTHSPRING MA|477.50||||||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Medicaid|MEDICAID|477.50||||477.50||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|477.50||||||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Medicare|MEDICARE ACUTE|477.50||||477.50||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Veterans Affairs|VETERANS ADMINISTRATION|477.50||||||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|477.50||||477.50||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Workers Compensation|WORKERS COMPENSATION OTHER|477.50||||||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Humana Medicare Advantage|HUMANA MA|477.50||||||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Managed Medicaid|MEDICAID AMERIGROUP|477.50||||||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|477.50||||||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Managed Medicaid|MEDICAID SUPERIOR|||||477.50||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Aenta Medicare Advantage|AETNA MEDICARE MA|477.50||||||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Blue Cross HMO Specialty|BCBSTX HMO|477.50||||||| 9521568|ERX|0250|LEVOFLOXACIN 500MG/100ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|477.50||||||| 9521576|ERX|0250|TRIAMCINOLONE 40MG/ML, 5M|Aenta Medicare Advantage|AETNA MEDICARE MA|||||438.50||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||0.06||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|Tricare|TRICARE EAST REGION|||||0.06||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|Managed Medicare|WELLCARE CHOICE MA|||||0.06||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|Medicaid|MEDICAID TEXAS CHILDRENS|||||0.06||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||0.06||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|Medicaid|MEDICAID|||||0.06||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|0.06||||0.06||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|NON CONTRACTED|COMMERCIAL OTHER 1|0.06||||||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|United Healthcare|UNITED HEALTHCARE|0.06||||0.06||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|United Healthcare|UNITED HEALTHCARE|||||0.06||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||0.06||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||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|Managed Medicaid|MEDICAID AMERIGROUP|0.06||||0.06||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.06||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|Blue Cross HMO Specialty|BCBSTX HMO|||||0.06||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|Blue Cross PPO Specialty|BCBSTX PPO|||||0.06||| 9521618|ERX|0250|IBUPROFEN 100MG/5ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.06||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Aetna|AETNA PPO|||||135.25||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Humana Medicare Advantage|HUMANA MA|135.25||||135.25||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|135.25||||135.25||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|||||135.25||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|135.25||||||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|135.25||||135.25||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||135.25||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|135.25||||||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Rusk State Hospital|RUSK STATE HOSP|135.25||||135.25||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|135.25||||||| 9521642|ERX|0250|HALOPERIDOL 5MG/1ML|Medicare|MEDICARE ACUTE|135.25||||135.25||| 9521667|ERX|0250|TOPIRAMATE 25MG TABLET|Medicare|MEDICARE ACUTE|24.50||||||| 9521667|ERX|0250|TOPIRAMATE 25MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||24.50||| 9521667|ERX|0250|TOPIRAMATE 25MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|24.50||||||| 9521667|ERX|0250|TOPIRAMATE 25MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|24.50||||||| 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 HMO Specialty|BCBSTX HMO|||||65.25||| 9521675|ERX|0250|TOPIRAMATE 100MG TABLET|United Healthcare|UMR UNITED MEDICAL RESOURCES|65.25||||||| 9521675|ERX|0250|TOPIRAMATE 100MG TABLET|Rusk State Hospital|RUSK STATE HOSP|65.25||||||| 9521675|ERX|0250|TOPIRAMATE 100MG TABLET|Medicare|MEDICARE ACUTE|65.25||||||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|18.25||||||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Medicaid|MEDICAID|18.25||||||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Medicaid|COUNTY INDIGENT HEALTH OTHER|18.25||||||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|18.25||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Medicare|MEDICARE ACUTE|18.25||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Medicare|MEDICARE PART B ONLY IP|18.25||||||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|18.25||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|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|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||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|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|United Healthcare|UNITED HEALTHCARE OTHER|||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|United Healthcare|UNITED HEALTHCARE|||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|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||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|18.25||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|18.25||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Managed Medicare|HEALTHSPRING MA|18.25||||||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UMR|||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH 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|Humana Medicare Advantage|HUMANA MA|18.25||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Cigna|CIGNA|18.25||||||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|18.25||||||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|18.25||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|||||18.25||| 9521709|ERX|0250|TRAMADOL 50MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|18.25||||18.25||| 9521733|ERX|0250|LEVOFLOXACIN 250MG TABLET|Humana Medicare Advantage|HUMANA MA|116.25||||116.25||| 9521733|ERX|0250|LEVOFLOXACIN 250MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|116.25||||||| 9521733|ERX|0250|LEVOFLOXACIN 250MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|116.25||||||| 9521733|ERX|0250|LEVOFLOXACIN 250MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|116.25||||||| 9521733|ERX|0250|LEVOFLOXACIN 250MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|116.25||||||| 9521733|ERX|0250|LEVOFLOXACIN 250MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|116.25||||||| 9521733|ERX|0250|LEVOFLOXACIN 250MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|116.25||||||| 9521733|ERX|0250|LEVOFLOXACIN 250MG TABLET|Medicare|MEDICARE ACUTE|116.25||||||| 9521733|ERX|0250|LEVOFLOXACIN 250MG TABLET|Medicaid|MEDICAID|116.25||||||| 9521741|ERX|0250|LEVOFLOXACIN 500MG TABLET|Medicare|MEDICARE ACUTE|1.33||||1.33||| 9521741|ERX|0250|LEVOFLOXACIN 500MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|1.33||||||| 9521741|ERX|0250|LEVOFLOXACIN 500MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.33||||1.33||| 9521741|ERX|0250|LEVOFLOXACIN 500MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|1.33||||1.33||| 9521741|ERX|0250|LEVOFLOXACIN 500MG TABLET|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||1.33||| 9521741|ERX|0250|LEVOFLOXACIN 500MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|1.33||||||| 9521741|ERX|0250|LEVOFLOXACIN 500MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|1.33||||1.33||| 9521741|ERX|0250|LEVOFLOXACIN 500MG TABLET|Humana Medicare Advantage|HUMANA MA|1.33||||1.33||| 9521741|ERX|0250|LEVOFLOXACIN 500MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|||||1.33||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|Humana Medicare Advantage|HUMANA MA|247.50||||||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|Cigna|CIGNA|247.50||||||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|247.50||||||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|247.50||||||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||247.50||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|247.50||||||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|247.50||||||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|Medicaid|MEDICAID|247.50||||||| 9521758|ERX|0250|LEVOFLOXACIN 750MG TABLET|Medicare|MEDICARE ACUTE|247.50||||||| 9521782|ERX|0250|ESTROGENS,CONJ 0.625MG TA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|18.25||||||| 9521808|ERX|0250|ESTROGENS,CONJ VAG CRM,42|Humana Medicare Advantage|HUMANA MA|1,035.75||||||| 9521980|ERX|0250|DOXAZOSIN 2MG TABLET|Medicare|MEDICARE ACUTE|0.20||||||| 9521980|ERX|0250|DOXAZOSIN 2MG TABLET|Humana Medicare Advantage|HUMANA MA|0.20||||||| 9522038|ERX|0250|FLUCONAZOLE 200MG/100ML N|Aenta Medicare Advantage|AETNA MEDICARE MA|163.75||||||| 9522038|ERX|0250|FLUCONAZOLE 200MG/100ML N|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||163.75||| 9522038|ERX|0250|FLUCONAZOLE 200MG/100ML N|Medicare|MEDICARE ACUTE|163.75||||163.75||| 9522053|ERX|0250|FLUCONAZOLE 100MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|117.50||||||| 9522053|ERX|0250|FLUCONAZOLE 100MG TABLET|Medicare|MEDICARE ACUTE|117.50||||||| 9522053|ERX|0250|FLUCONAZOLE 100MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|||||117.50||| 9522053|ERX|0250|FLUCONAZOLE 100MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||117.50||| 9522053|ERX|0250|FLUCONAZOLE 100MG TABLET|Humana Medicare Advantage|HUMANA MA|117.50||||||| 9522053|ERX|0250|FLUCONAZOLE 100MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||117.50||| 9522053|ERX|0250|FLUCONAZOLE 100MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|117.50||||||| 9522053|ERX|0250|FLUCONAZOLE 100MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|117.50||||||| 9522079|ERX|0250|FLUCONAZOLE 400MG/200ML N|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|261.25||||||| 9522079|ERX|0250|FLUCONAZOLE 400MG/200ML N|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|261.25||||||| 9522079|ERX|0250|FLUCONAZOLE 400MG/200ML N|UTMB|UTMB CORRECTIONAL MANAGED CARE|261.25||||||| 9522079|ERX|0250|FLUCONAZOLE 400MG/200ML N|Medicare|MEDICARE ACUTE|261.25||||||| 9522095|ERX|0250|FLUCONAZOLE 40MG/ML, 35ML|Medicaid|MEDICAID HMO|||||273.25||| 9522095|ERX|0250|FLUCONAZOLE 40MG/ML, 35ML|Medicaid|MEDICAID|273.25||||||| 9522095|ERX|0250|FLUCONAZOLE 40MG/ML, 35ML|Managed Medicaid|MEDICAID SUPERIOR|273.25||||||| 9522103|ERX|0250|ZIPRASIDONE 20MG/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.45||||||| 9522103|ERX|0250|ZIPRASIDONE 20MG/1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|1.45||||||| 9522103|ERX|0250|ZIPRASIDONE 20MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.45||||1.45||| 9522103|ERX|0250|ZIPRASIDONE 20MG/1ML|Rusk State Hospital|RUSK STATE HOSP|1.45||||1.45||| 9522103|ERX|0250|ZIPRASIDONE 20MG/1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||1.45||| 9522103|ERX|0250|ZIPRASIDONE 20MG/1ML|Medicare|MEDICARE ACUTE|1.45||||1.45||| 9522111|ERX|0250|ZIPRASIDONE 20MG CAPSULE|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.65||||||| 9522111|ERX|0250|ZIPRASIDONE 20MG CAPSULE|Medicare|MEDICARE ACUTE|0.65||||||| 9522111|ERX|0250|ZIPRASIDONE 20MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.65||| 9522111|ERX|0250|ZIPRASIDONE 20MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.65||| 9522111|ERX|0250|ZIPRASIDONE 20MG CAPSULE|United Healthcare|UMR UNITED MEDICAL RESOURCES|0.65||||||| 9522129|ERX|0250|ZIPRASIDONE 40MG CAPSULE|United Healthcare|UMR UNITED MEDICAL RESOURCES|0.65||||||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|36.75||||||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||36.75||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Medicare|MEDICARE ACUTE|36.75||||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|Managed Medicaid|MEDICAID AMERIGROUP|36.75||||||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|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|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|36.75||||36.75||| 9522152|ERX|0250|SERTRALINE 50MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|36.75||||||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|United Healthcare|UNITED HEALTHCARE OTHER|196.25||||196.25||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|United Healthcare|UNITED HEALTHCARE|196.25||||196.25||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|United Healthcare|UMR UNITED MEDICAL RESOURCES|196.25||||||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Veterans Affairs|VETERANS ADMINISTRATION|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|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|196.25||||196.25||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|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|Brinson Benefits|THE HEALTH PLAN SMITH CO|196.25||||196.25||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|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 CIGNA HEALTHSPRING|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 Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|196.25||||196.25||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Humana Medicare Advantage|HUMANA MA|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|Blue Cross HMO Specialty|BCBSTX HMO|196.25||||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 UTH UMR|||||196.25||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Access Direct Platinum|HEALTHFIRST TPA UMR|||||196.25||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Aetna|AETNA PPO|196.25||||196.25||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Aetna|AETNA OTHER|||||196.25||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Blue Cross PPO Specialty|BCBSTX OTHER|||||196.25||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|United Healthcare|UNITED HEALTHCARE|196.25||||||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Blue Cross PPO Specialty|BCBSTX PPO|196.25||||196.25||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Medicare|MEDICARE ACUTE|196.25||||196.25||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|NON CONTRACTED|COMMERCIAL OTHER 1|196.25||||196.25||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|196.25||||||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Tricare|TRICARE EAST REGION|196.25||||196.25||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Managed Medicare|BCBS MEDICARE PPO MA|||||196.25||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Managed Medicare|HEALTHSPRING MA|196.25||||||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||196.25||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Medicaid|MEDICAID|196.25||||196.25||| 9522236|ERX|0250|ROCURONIUM 50MG/5ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||196.25||| 9522269|ERX|0250|NYSTATIN POWDER, 15 GM|Medicare|MEDICARE ACUTE|313.50||||||| 9522269|ERX|0250|NYSTATIN POWDER, 15 GM|Aetna|AETNA OTHER|313.50||||||| 9522269|ERX|0250|NYSTATIN POWDER, 15 GM|Humana Medicare Advantage|HUMANA MA|313.50||||||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|United Healthcare|UNITED HEALTHCARE 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|Workers Compensation|UT EMPLOYEE INJURY|||||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||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|0.04||||0.04||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.04||||0.04||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|||||0.04||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||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|Aenta Medicare Advantage|AETNA MEDICARE MA|0.04||||0.04||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|||||0.04||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Aetna|AETNA OTHER|0.04||||||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.04||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.04||||0.04||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Medicaid|MEDICAID HMO|||||0.04||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Medicaid|MEDICAID TEXAS CHILDRENS|||||0.04||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Medicaid|MEDICAID|0.04||||0.04||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.04||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Medicare|MEDICARE ACUTE|0.04||||0.04||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.04||||||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.04||||0.04||| 9522301|ERX|0250|PREDNISONE 20MG TABLET|Rusk State Hospital|RUSK STATE HOSP|0.04||||||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|Rusk State Hospital|RUSK STATE HOSP|85.75||||||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|Medicare|MEDICARE ACUTE|85.75||||85.75||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|UTMB|UTMB CORRECTIONAL MANAGED CARE|85.75||||||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|85.75||||||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|Aenta Medicare Advantage|AETNA MEDICARE MA|85.75||||85.75||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|Aetna|AETNA PPO|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 CIGNA HEALTHSPRING|85.75||||85.75||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|United Healthcare|UNITED HEALTHCARE OTHER|||||85.75||| 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||||85.75||| 9522343|ERX|0250|NA POLYSTY SULFONATE 15G/|United Medicare Advantage|AARP UHC WEST COMPLETE MA|85.75||||||| 9522434|ERX|0250|HYDROXYUREA 500MG CAPSULE|Humana Medicare Advantage|HUMANA MA|0.18||||||| 9522434|ERX|0250|HYDROXYUREA 500MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|0.18||||||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.09||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|Medicare|MEDICARE ACUTE|0.09||||||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|Rusk State Hospital|RUSK STATE HOSP|0.09||||||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.09||||||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|0.09||||0.09||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||0.09||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.09||||||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.09||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.09||||||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|Humana Medicare Advantage|HUMANA MA|0.09||||||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||0.09||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.09||||||| 9522608|ERX|0250|DEXAMETHASONE 4MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|||||0.09||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Humana Medicare Advantage|HUMANA MA|15.50||||15.50||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||15.50||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Managed Medicaid|MEDICAID SUPERIOR|15.50||||15.50||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Managed Medicaid|MEDICAID AMERIGROUP|15.50||||15.50||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||15.50||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||15.50||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Blue Cross HMO Specialty|BCBSTX HMO|||||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,|Access Direct Platinum|HEALTHFIRST TPA UMR|||||15.50||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Blue Cross PPO Specialty|BCBSTX OTHER|||||15.50||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Blue Cross PPO Specialty|BCBSTX PPO|||||15.50||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|United Healthcare|UNITED HEALTHCARE OTHER|15.50||||15.50||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|United Healthcare|UNITED HEALTHCARE|||||15.50||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||15.50||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|United Medicare Advantage|UHC MEDICARE GOLD MA|15.50||||||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||15.50||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Medicare|MEDICARE ACUTE|15.50||||15.50||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|NON CONTRACTED|COMMERCIAL OTHER 1|||||15.50||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Tricare|TRICARE EAST REGION|||||15.50||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||15.50||| 9522640|ERX|0250|LIDOCAINE 2% VISCOUS 5ML,|Managed Medicare|HEALTHSPRING MA|||||15.50||| 9522665|ERX|0250|LITHIUM 300MG CAPSULE|Medicare|MEDICARE ACUTE|12.50||||||| 9522665|ERX|0250|LITHIUM 300MG CAPSULE|Rusk State Hospital|RUSK STATE HOSP|12.50||||||| 9522665|ERX|0250|LITHIUM 300MG CAPSULE|United Healthcare|UMR UNITED MEDICAL RESOURCES|12.50||||||| 9522665|ERX|0250|LITHIUM 300MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||12.50||| 9522665|ERX|0250|LITHIUM 300MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|||||12.50||| 9522673|ERX|0250|METHOTREXATE 2.5MG TABLET|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|0.35||||||| 9522707|ERX|0250|METHADONE 10MG TABLET|Medicare|MEDICARE ACUTE|||||7.50||| 9522707|ERX|0250|METHADONE 10MG TABLET|Cigna|CIGNA|7.50||||||| 9522707|ERX|0250|METHADONE 10MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|7.50||||||| 9522707|ERX|0250|METHADONE 10MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||7.50||| 9522707|ERX|0250|METHADONE 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.50||||||| 9522723|ERX|0250|PREDNISONE 1MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|4.75||||||| 9522731|ERX|0250|WARFARIN 1MG TABLET|Managed Medicare|HEALTHSPRING MA|14.50||||||| 9522731|ERX|0250|WARFARIN 1MG TABLET|Humana Medicare Advantage|HUMANA MA|14.50||||||| 9522749|ERX|0250|WARFARIN 2MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.15||||||| 9522749|ERX|0250|WARFARIN 2MG TABLET|Humana Medicare Advantage|HUMANA MA|0.15||||||| 9522749|ERX|0250|WARFARIN 2MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.15||||||| 9522749|ERX|0250|WARFARIN 2MG TABLET|Medicare|MEDICARE ACUTE|0.15||||0.15||| 9522756|ERX|0250|WARFARIN 5MG TABLET|Medicare|MEDICARE ACUTE|0.15||||||| 9522756|ERX|0250|WARFARIN 5MG TABLET|Humana Medicare Advantage|HUMANA MA|0.15||||||| 9522756|ERX|0250|WARFARIN 5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.15||||||| 9522780|ERX|0250|WARFARIN 2.5MG TABLET|Managed Medicare|HEALTHSPRING MA|0.15||||||| 9522780|ERX|0250|WARFARIN 2.5MG TABLET|Medicare|MEDICARE ACUTE|0.15||||0.15||| 9522913|ERX|0250|COLLAGENASE OINT, 30 GM|Medicare|MEDICARE ACUTE|7.33||||||| 9522913|ERX|0250|COLLAGENASE OINT, 30 GM|Medicaid|MEDICAID|7.33||||||| 9523044|ERX|0250|TOBRAMYCIN 0.3% EYE DROP,|Workers Compensation|UT EMPLOYEE INJURY|||||606.25||| 9523044|ERX|0250|TOBRAMYCIN 0.3% EYE DROP,|Blue Cross PPO Specialty|BCBSTX PPO|||||606.25||| 9523044|ERX|0250|TOBRAMYCIN 0.3% EYE DROP,|Humana Medicare Advantage|HUMANA MA|606.25||||||| 9523044|ERX|0250|TOBRAMYCIN 0.3% EYE DROP,|Medicare|MEDICARE ACUTE|606.25||||||| 9523069|ERX|0250|TOBRAMYCIN/DEXAMETH, 2.5M|Workers Compensation|UT EMPLOYEE INJURY|||||405.25||| 9523135|ERX|0250|TETRACAINE 0.5% EYE DROP,|Medicaid|MEDICAID|||||0.75||| 9523135|ERX|0250|TETRACAINE 0.5% EYE DROP,|Rusk State Hospital|RUSK STATE HOSP|||||0.75||| 9523135|ERX|0250|TETRACAINE 0.5% EYE DROP,|Humana Medicare Advantage|HUMANA MA|||||0.75||| 9523135|ERX|0250|TETRACAINE 0.5% EYE DROP,|Cigna|CIGNA|||||0.75||| 9523135|ERX|0250|TETRACAINE 0.5% EYE DROP,|Managed Medicaid|MEDICAID AMERIGROUP|||||0.75||| 9523135|ERX|0250|TETRACAINE 0.5% EYE DROP,|Blue Cross PPO Specialty|BCBSTX PPO|||||0.75||| 9523135|ERX|0250|TETRACAINE 0.5% EYE DROP,|United Healthcare|UNITED HEALTHCARE OTHER|||||0.75||| 9523135|ERX|0250|TETRACAINE 0.5% EYE DROP,|Workers Compensation|UT EMPLOYEE INJURY|||||0.75||| 9523135|ERX|0250|TETRACAINE 0.5% EYE DROP,|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.75||| 9523135|ERX|0250|TETRACAINE 0.5% EYE DROP,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.75||| 9523135|ERX|0250|TETRACAINE 0.5% EYE DROP,|Workers Compensation|WORKERS COMPENSATION OTHER|||||0.75||| 9523184|ERX|0250|CIPROFLOX-DEXAMETH DROP,|Managed Medicaid|MEDICAID SUPERIOR|||||6.78||| 9523184|ERX|0250|CIPROFLOX-DEXAMETH DROP,|UTMB|UTMB CORRECTIONAL MANAGED CARE|6.78||||||| 9523226|ERX|0250|TERBINAFINE 1% CREAM, 12|Aenta Medicare Advantage|AETNA MEDICARE MA|88.50||||||| 9523234|ERX|0250|SCOPOLAMINE 1.5MG PATCH|Medicare|MEDICARE ACUTE|0.94||||||| 9523242|ERX|0250|NICOTINE 7MG PATCH|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||26.25||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Managed Medicare|HEALTHSPRING MA|26.25||||||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Medicare|MEDICARE ACUTE|26.25||||||| 9523259|ERX|0250|NICOTINE 14MG PATCH|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||26.25||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|26.25||||26.25||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Blue Cross HMO Specialty|BCBSTX HMO|26.25||||||| 9523259|ERX|0250|NICOTINE 14MG PATCH|Blue Cross PPO Specialty|BCBSTX PPO|26.25||||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||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Managed Medicaid|MEDICAID SUPERIOR|26.25||||26.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Managed Medicaid|MEDICAID AMERIGROUP|26.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|26.25||||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 UNITED HEALTHCARE|26.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Aenta Medicare Advantage|AETNA MEDICARE MA|26.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Blue Cross HMO Specialty|BCBSTX HMO|||||26.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Blue Cross PPO Specialty|BCBSTX PPO|||||26.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Veterans Affairs|VETERANS ADMINISTRATION|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|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|26.25||||26.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Medicare|MEDICARE ACUTE|26.25||||26.25||| 9523267|ERX|0250|NICOTINE 21MG PATCH|NON CONTRACTED|COMMERCIAL OTHER 1|26.25||||||| 9523267|ERX|0250|NICOTINE 21MG PATCH|Medicaid|MEDICAID|||||26.25||| 9523325|ERX|0250|RIFAMPIN 600MG VIAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|9.85||||||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|27.50||||||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||27.50||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|27.50||||||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|27.50||||||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|27.50||||||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|27.50||||||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|27.50||||||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Humana Medicare Advantage|HUMANA MA|27.50||||||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|27.50||||||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||27.50||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||27.50||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|27.50||||||| 9523358|ERX|0250|CETIRIZINE 10MG TABLET|Medicare|MEDICARE ACUTE|27.50||||27.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||24.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Medicaid|MEDICAID|24.50||||||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Medicare|MEDICARE ACUTE|24.50||||24.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|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 CIGNA HEALTHSPRING|24.50||||||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|24.50||||||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|24.50||||||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|24.50||||24.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|24.50||||24.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|24.50||||||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|United Healthcare|UMR UNITED MEDICAL RESOURCES|24.50||||||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|24.50||||||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|24.50||||24.50||| 9523408|ERX|0250|AMLODIPINE 5MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|24.50||||24.50||| 9523416|ERX|0250|AMLODIPINE 10MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|||||29.50||| 9523416|ERX|0250|AMLODIPINE 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|29.50||||29.50||| 9523416|ERX|0250|AMLODIPINE 10MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|||||29.50||| 9523416|ERX|0250|AMLODIPINE 10MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|29.50||||||| 9523416|ERX|0250|AMLODIPINE 10MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|29.50||||||| 9523416|ERX|0250|AMLODIPINE 10MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|29.50||||||| 9523416|ERX|0250|AMLODIPINE 10MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|29.50||||||| 9523416|ERX|0250|AMLODIPINE 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|29.50||||29.50||| 9523416|ERX|0250|AMLODIPINE 10MG TABLET|Humana Medicare Advantage|HUMANA MA|29.50||||29.50||| 9523416|ERX|0250|AMLODIPINE 10MG TABLET|Cigna|CIGNA|29.50||||||| 9523416|ERX|0250|AMLODIPINE 10MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|29.50||||||| 9523416|ERX|0250|AMLODIPINE 10MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|29.50||||||| 9523416|ERX|0250|AMLODIPINE 10MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|29.50||||29.50||| 9523416|ERX|0250|AMLODIPINE 10MG TABLET|Medicare|MEDICARE ACUTE|29.50||||29.50||| 9523416|ERX|0250|AMLODIPINE 10MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|29.50||||||| 9523416|ERX|0250|AMLODIPINE 10MG TABLET|Rusk State Hospital|RUSK STATE HOSP|29.50||||||| 9523416|ERX|0250|AMLODIPINE 10MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|29.50||||||| 9523416|ERX|0250|AMLODIPINE 10MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|29.50||||||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Medicaid|MEDICAID|1.05||||||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.05||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Medicare|MEDICARE ACUTE|1.05||||1.05||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Rusk State Hospital|RUSK STATE HOSP|1.05||||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||||1.05||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Humana Medicare Advantage|HUMANA MA|||||1.05||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|1.05||||1.05||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Cigna|CIGNA|||||1.05||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||1.05||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|1.05||||||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1.05||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.05||||1.05||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|||||1.05||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.05||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|1.05||||1.05||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.05||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||1.05||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|United Healthcare|UNITED HEALTHCARE|||||1.05||| 9523432|ERX|0250|AZITHROMYCIN 250MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|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|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|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|Workers Compensation|WORKERS COMPENSATION OTHER|1.05||||||| 9523465|ERX|0250|AZITHROMYCIN 200MG/5ML,22|Managed Medicaid|MEDICAID SUPERIOR|443.50||||443.50||| 9523465|ERX|0250|AZITHROMYCIN 200MG/5ML,22|Managed Medicaid|MEDICAID AMERIGROUP|||||443.50||| 9523465|ERX|0250|AZITHROMYCIN 200MG/5ML,22|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||443.50||| 9523465|ERX|0250|AZITHROMYCIN 200MG/5ML,22|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||443.50||| 9523465|ERX|0250|AZITHROMYCIN 200MG/5ML,22|Medicaid|SUPERIOR HEALTHPLAN CHIP|443.50||||443.50||| 9523465|ERX|0250|AZITHROMYCIN 200MG/5ML,22|Medicaid|MEDICAID|443.50||||443.50||| 9523465|ERX|0250|AZITHROMYCIN 200MG/5ML,22|Medicaid|MEDICAID HMO|||||443.50||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|Medicare|MEDICARE ACUTE|353.50||||||| 9523473|ERX|0250|AZITHROMYCIN 500MG VIAL|NON CONTRACTED|COMMERCIAL OTHER 1|353.50||||||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|United Healthcare|UNITED HEALTHCARE|31.50||||||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|31.50||||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|Workers Compensation|WORKERS COMPENSATION OTHER|31.50||||||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|31.50||||||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|31.50||||||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Humana Medicare Advantage|HUMANA MA|31.50||||||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|31.50||||||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Medicaid|MEDICAID|31.50||||||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Medicare|MEDICARE ACUTE|31.50||||||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|Rusk State Hospital|RUSK STATE HOSP|31.50||||||| 9523523|ERX|0250|ATORVASTATIN 10MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|31.50||||||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Medicare|MEDICARE PART B ONLY IP|0.45||||||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Medicare|MEDICARE ACUTE|0.45||||0.45||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.45||||||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.45||||||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Managed Medicare|HEALTHSPRING MA|0.45||||||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.45||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Medicaid|MEDICAID|0.45||||||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Humana Medicare Advantage|HUMANA MA|0.45||||0.45||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.45||||||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.45||||||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Rusk State Hospital|RUSK STATE HOSP|0.45||||||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.45||||0.45||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.45||||||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.45||||0.45||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Aetna|AETNA PPO|0.45||||||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.45||||||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.45||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.45||||0.45||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|0.45||||0.45||| 9523531|ERX|0250|ATORVASTATIN 20MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.45||||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 MEDICARE GOLD MA|0.45||||||| 9523549|ERX|0250|ATORVASTATIN 40MG TABLET|Medicare|MEDICARE ACUTE|0.45||||||| 9523598|ERX|0250|PHENYTOIN 100MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.50||||7.50||| 9523598|ERX|0250|PHENYTOIN 100MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|7.50||||||| 9523598|ERX|0250|PHENYTOIN 100MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.50||||||| 9523598|ERX|0250|PHENYTOIN 100MG CAPSULE|Medicare|MEDICARE ACUTE|7.50||||||| 9523598|ERX|0250|PHENYTOIN 100MG CAPSULE|UTMB|UTMB CORRECTIONAL MANAGED CARE|7.50||||7.50||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Medicaid|MEDICAID|0.13||||||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Medicare|MEDICARE ACUTE|0.13||||0.13||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Humana Medicare Advantage|HUMANA MA|0.13||||0.13||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.13||||||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|||||0.13||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|0.13||||0.13||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|Blue Cross PPO Specialty|BCBSTX OTHER|||||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|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.13||||0.13||| 9523614|ERX|0250|GABAPENTIN 100MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.13||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|United Healthcare|UNITED HEALTHCARE OTHER|||||24.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|United Healthcare|UNITED HEALTHCARE|||||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|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|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|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|24.50||||||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|24.50||||||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|24.50||||24.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|24.50||||||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|||||24.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Blue Cross PPO Specialty|BCBSTX OTHER|||||24.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|||||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 SUPERIOR|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|Managed Medicaid|MEDICAID AMERIGROUP|||||24.50||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|24.50||||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|NON CONTRACTED|COMMERCIAL OTHER 1|24.50||||||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|24.50||||||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Managed Medicare|HEALTHSPRING MA|24.50||||||| 9523622|ERX|0250|GABAPENTIN 300MG CAPSULE|Medicaid|MEDICAID|24.50||||24.50||| 9523630|ERX|0250|GABAPENTIN 400MG CAPSULE|Medicare|MEDICARE ACUTE|24.50||||24.50||| 9523630|ERX|0250|GABAPENTIN 400MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|24.50||||||| 9523630|ERX|0250|GABAPENTIN 400MG CAPSULE|Humana Medicare Advantage|HUMANA MA|24.50||||24.50||| 9523630|ERX|0250|GABAPENTIN 400MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|24.50||||24.50||| 9523630|ERX|0250|GABAPENTIN 400MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|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||||||| 9523648|ERX|0250|PREGABALIN 25MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||24.50||| 9523655|ERX|0250|PREGABALIN 50MG CAPSULE|Medicare|MEDICARE PART B ONLY IP|24.50||||||| 9523655|ERX|0250|PREGABALIN 50MG CAPSULE|Medicare|MEDICARE ACUTE|24.50||||||| 9523655|ERX|0250|PREGABALIN 50MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|24.50||||||| 9523655|ERX|0250|PREGABALIN 50MG CAPSULE|Humana Medicare Advantage|HUMANA MA|24.50||||||| 9523655|ERX|0250|PREGABALIN 50MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|24.50||||||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|United Healthcare|UMR UNITED MEDICAL RESOURCES|24.50||||||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|24.50||||||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|24.50||||||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|Humana Medicare Advantage|HUMANA MA|24.50||||||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||24.50||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|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|Medicare|MEDICARE ACUTE|24.50||||24.50||| 9523663|ERX|0250|PREGABALIN 75MG CAPSULE|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||24.50||| 9523689|ERX|0250|CLONAZEPAM 1MG TABLET|Medicare|MEDICARE ACUTE|20.25||||20.25||| 9523689|ERX|0250|CLONAZEPAM 1MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|20.25||||||| 9523689|ERX|0250|CLONAZEPAM 1MG TABLET|Rusk State Hospital|RUSK STATE HOSP|20.25||||||| 9523689|ERX|0250|CLONAZEPAM 1MG TABLET|Humana Medicare Advantage|HUMANA MA|20.25||||||| 9523689|ERX|0250|CLONAZEPAM 1MG TABLET|Cigna|CIGNA|20.25||||||| 9523689|ERX|0250|CLONAZEPAM 1MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|20.25||||||| 9523689|ERX|0250|CLONAZEPAM 1MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||20.25||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||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|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.18||||||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|Humana Medicare Advantage|HUMANA MA|0.18||||0.18||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|Cigna|CIGNA|0.18||||||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.18||||||| 9523754|ERX|0250|CLONAZEPAM 0.5MG TABLET|Medicare|MEDICARE ACUTE|0.18||||||| 9523762|ERX|0250|VALPROATE 500MG 5ML|Medicaid|MEDICAID|||||184.50||| 9523762|ERX|0250|VALPROATE 500MG 5ML|Medicare|MEDICARE ACUTE|184.50||||||| 9523762|ERX|0250|VALPROATE 500MG 5ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||184.50||| 9523804|ERX|0250|HYDROMORPHONE 2MG TABLET|United Healthcare|UMR UNITED MEDICAL RESOURCES|12.50||||||| 9523804|ERX|0250|HYDROMORPHONE 2MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|||||12.50||| 9523804|ERX|0250|HYDROMORPHONE 2MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12.50||||||| 9523804|ERX|0250|HYDROMORPHONE 2MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|12.50||||||| 9523804|ERX|0250|HYDROMORPHONE 2MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|12.50||||12.50||| 9523804|ERX|0250|HYDROMORPHONE 2MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|||||12.50||| 9523804|ERX|0250|HYDROMORPHONE 2MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|12.50||||||| 9523804|ERX|0250|HYDROMORPHONE 2MG TABLET|Cigna|CIGNA|12.50||||||| 9523804|ERX|0250|HYDROMORPHONE 2MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|12.50||||||| 9523804|ERX|0250|HYDROMORPHONE 2MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|12.50||||||| 9523804|ERX|0250|HYDROMORPHONE 2MG TABLET|Medicare|MEDICARE ACUTE|12.50||||||| 9523895|ERX|0250|DULOXETINE 20MG CAPSULE|Medicare|MEDICARE ACUTE|37.50||||||| 9523895|ERX|0250|DULOXETINE 20MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|37.50||||||| 9523960|ERX|0250|CEFDINIR 300MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|0.59||||||| 9523960|ERX|0250|CEFDINIR 300MG CAPSULE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.59||||||| 9523960|ERX|0250|CEFDINIR 300MG CAPSULE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.59||||||| 9523960|ERX|0250|CEFDINIR 300MG CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|0.59||||||| 9523960|ERX|0250|CEFDINIR 300MG CAPSULE|Humana Medicare Advantage|HUMANA MA|0.59||||0.59||| 9523960|ERX|0250|CEFDINIR 300MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.59||||||| 9523960|ERX|0250|CEFDINIR 300MG CAPSULE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.59||||||| 9523960|ERX|0250|CEFDINIR 300MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|0.59||||||| 9523960|ERX|0250|CEFDINIR 300MG CAPSULE|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.59||||||| 9523960|ERX|0250|CEFDINIR 300MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|0.59||||||| 9523960|ERX|0250|CEFDINIR 300MG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.59||||||| 9523960|ERX|0250|CEFDINIR 300MG CAPSULE|Medicaid|MEDICAID|0.59||||||| 9523960|ERX|0250|CEFDINIR 300MG CAPSULE|Medicare|MEDICARE ACUTE|0.59||||||| 9523960|ERX|0250|CEFDINIR 300MG CAPSULE|Rusk State Hospital|RUSK STATE HOSP|0.59||||||| 9523986|ERX|0250|TERAZOSIN 1MG CAPSULE|UTMB|UTMB CORRECTIONAL MANAGED CARE|24.50||||||| 9523986|ERX|0250|TERAZOSIN 1MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|24.50||||||| 9524000|ERX|0250|TERAZOSIN 5MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|24.50||||||| 9524000|ERX|0250|TERAZOSIN 5MG CAPSULE|Humana Medicare Advantage|HUMANA MA|24.50||||||| 9524000|ERX|0250|TERAZOSIN 5MG CAPSULE|Medicare|MEDICARE ACUTE|||||24.50||| 9524000|ERX|0250|TERAZOSIN 5MG CAPSULE|UTMB|UTMB CORRECTIONAL MANAGED CARE|24.50||||||| 9524018|ERX|0250|DIVALPROEX ER 250MG TABLE|Medicaid|MEDICAID|21.25||||||| 9524018|ERX|0250|DIVALPROEX ER 250MG TABLE|Medicare|MEDICARE ACUTE|21.25||||||| 9524018|ERX|0250|DIVALPROEX ER 250MG TABLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|21.25||||||| 9524083|ERX|0250|VALPROATE NA 250MG/5ML,30|Medicare|MEDICARE ACUTE|176.25||||||| 9524083|ERX|0250|VALPROATE NA 250MG/5ML,30|Rusk State Hospital|RUSK STATE HOSP|176.25||||||| 9524117|ERX|0250|DIVALPROEX 250MG TABLET|Humana Medicare Advantage|HUMANA MA|24.50||||||| 9524117|ERX|0250|DIVALPROEX 250MG TABLET|Medicaid|MEDICAID|24.50||||||| 9524117|ERX|0250|DIVALPROEX 250MG TABLET|Medicare|MEDICARE ACUTE|24.50||||||| 9524125|ERX|0250|DIVALPROEX 500MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|36.75||||36.75||| 9524125|ERX|0250|DIVALPROEX 500MG TABLET|Medicare|MEDICARE ACUTE|36.75||||||| 9524125|ERX|0250|DIVALPROEX 500MG TABLET|Rusk State Hospital|RUSK STATE HOSP|36.75||||||| 9524125|ERX|0250|DIVALPROEX 500MG TABLET|Medicaid|MEDICAID|||||36.75||| 9524125|ERX|0250|DIVALPROEX 500MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|36.75||||||| 9524125|ERX|0250|DIVALPROEX 500MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|36.75||||36.75||| 9524166|ERX|0250|ERYTHROMYCIN BASE 250MG T|Medicaid|MEDICAID|0.25||||||| 9524208|ERX|0250|DIVALPROEX ER 500MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.30||||||| 9524208|ERX|0250|DIVALPROEX ER 500MG TABLE|Medicare|MEDICARE ACUTE|0.30||||||| 9524208|ERX|0250|DIVALPROEX ER 500MG TABLE|Rusk State Hospital|RUSK STATE HOSP|0.30||||||| 9524208|ERX|0250|DIVALPROEX ER 500MG TABLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.30||||||| 9524208|ERX|0250|DIVALPROEX ER 500MG TABLE|Medicaid|MEDICAID|0.30||||0.30||| 9524232|ERX|0250|DESMOPRESSIN 0.1MG TABLET|Medicare|MEDICARE ACUTE|39.25||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|3.37||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|United Healthcare|UMR UNITED MEDICAL RESOURCES|3.37||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|United Medicare Advantage|UHC MEDICARE GOLD MA|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|United Medicare Advantage|AARP UHC WEST COMPLETE MA|3.37||||3.37||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|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|Blue Cross HMO Specialty|BCBSTX HMO|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||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Blue Cross PPO Specialty|BCBSTX OTHER|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|Workers Compensation|WORKERS COMPENSATION OTHER|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|Brinson Benefits|THE HEALTH PLAN SMITH CO|3.37||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Veterans Affairs|VETERANS ADMINISTRATION|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 UNITED HEALTHCARE|3.37||||3.37||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.37||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Managed Medicaid|MEDICAID AMERIGROUP|3.37||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Managed Medicaid|MEDICAID SUPERIOR|3.37||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Managed Medicare|HEALTHSPRING MA|3.37||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.37||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Medicaid|MEDICAID|3.37||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Medicare|MEDICARE PART B ONLY IP|3.37||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Medicare|MEDICARE ACUTE|3.37||||3.37||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|NON CONTRACTED|COMMERCIAL OTHER 1|3.37||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|Rusk State Hospital|RUSK STATE HOSP|3.37||||||| 9524257|ERX|0250|ENOXAPARIN 40MG/0.4ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.37||||||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|Medicare|MEDICARE ACUTE|493.75||||493.75||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|NON CONTRACTED|COMMERCIAL OTHER 2|||||493.75||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|Rusk State Hospital|RUSK STATE HOSP|493.75||||||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|Medicaid|MEDICAID|493.75||||||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|Humana Medicare Advantage|HUMANA MA|||||493.75||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|493.75||||||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|Managed Medicaid|MEDICAID SUPERIOR|493.75||||||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|Blue Cross PPO Specialty|BCBSTX PPO|493.75||||||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|Aetna|AETNA PPO|493.75||||||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||493.75||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|493.75||||||| 9524265|ERX|0250|ENOXAPARIN 60MG/0.6ML|Workers Compensation|WORKERS COMPENSATION OTHER|493.75||||||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|606.75||||606.75||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||606.75||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||606.75||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||606.75||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Aenta Medicare Advantage|AETNA MEDICARE MA|606.75||||||| 9524273|ERX|0250|ENOXAPARIN 80MG/0.8ML|Aetna|AETNA PPO|||||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|Humana Medicare Advantage|HUMANA MA|606.75||||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|Medicaid|COUNTY INDIGENT HEALTH OTHER|758.75||||||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Medicare|MEDICARE ACUTE|758.75||||758.75||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|758.75||||||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Humana Medicare Advantage|HUMANA MA|758.75||||758.75||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Managed Medicaid|MEDICAID AMERIGROUP|758.75||||758.75||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|758.75||||||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|758.75||||||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Blue Cross HMO Specialty|BCBSTX HMO|758.75||||||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|||||758.75||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Blue Cross PPO Specialty|BCBSTX OTHER|758.75||||||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|Veterans Affairs|VETERANS ADMINISTRATION|||||758.75||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||758.75||| 9524281|ERX|0250|ENOXAPARIN 100MG/1ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||758.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|252.75||||||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|United Medicare Advantage|UHC MEDICARE GOLD MA|252.75||||||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Aenta Medicare Advantage|AETNA MEDICARE MA|252.75||||||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Blue Cross HMO Specialty|BCBSTX HMO|252.75||||||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Humana Medicare Advantage|HUMANA MA|252.75||||||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Managed Medicaid|MEDICAID SUPERIOR|252.75||||||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||252.75||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|252.75||||||| 9524299|ERX|0250|ENOXAPARIN 30MG/0.3ML|Medicare|MEDICARE ACUTE|252.75||||||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|Medicare|MEDICARE ACUTE|809.50||||809.50||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||809.50||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|Humana Medicare Advantage|HUMANA MA|809.50||||||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|Cigna|CIGNA|809.50||||||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|809.50||||||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|809.50||||||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|Aenta Medicare Advantage|AETNA MEDICARE MA|809.50||||||| 9524323|ERX|0250|ENOXAPARIN 120MG/0.8ML|Workers Compensation|UT EMPLOYEE INJURY|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|Workers Compensation|WORKERS COMPENSATION OTHER|||||809.50||| 9524349|ERX|0250|ENOXAPARIN 150MG/1ML|Humana Medicare Advantage|HUMANA MA|1,011.75||||||| 9524380|ERX|0250|BROMOCRIPTINE 2.5MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|47.25||||||| 9524398|ERX|0250|METHYLERGONOVINE 0.2MG/1M|Medicaid|MEDICAID|76.75||||||| 9524398|ERX|0250|METHYLERGONOVINE 0.2MG/1M|NON CONTRACTED|COMMERCIAL OTHER 1|76.75||||||| 9524398|ERX|0250|METHYLERGONOVINE 0.2MG/1M|Tricare|TRICARE EAST REGION|76.75||||||| 9524398|ERX|0250|METHYLERGONOVINE 0.2MG/1M|United Healthcare|UNITED HEALTHCARE OTHER|76.75||||||| 9524398|ERX|0250|METHYLERGONOVINE 0.2MG/1M|United Healthcare|UNITED HEALTHCARE|76.75||||||| 9524398|ERX|0250|METHYLERGONOVINE 0.2MG/1M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|76.75||||||| 9524398|ERX|0250|METHYLERGONOVINE 0.2MG/1M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|76.75||||||| 9524398|ERX|0250|METHYLERGONOVINE 0.2MG/1M|Blue Cross PPO Specialty|BCBSTX PPO|76.75||||||| 9524398|ERX|0250|METHYLERGONOVINE 0.2MG/1M|Managed Medicaid|MEDICAID SUPERIOR|76.75||||76.75||| 9524398|ERX|0250|METHYLERGONOVINE 0.2MG/1M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|76.75||||||| 9524398|ERX|0250|METHYLERGONOVINE 0.2MG/1M|Managed Medicaid|MEDICAID AMERIGROUP|76.75||||76.75||| 9524406|ERX|0250|METHYLERGONOVINE 0.2MG TA|Managed Medicaid|MEDICAID AMERIGROUP|324.45||||324.45||| 9524406|ERX|0250|METHYLERGONOVINE 0.2MG TA|Managed Medicaid|MEDICAID SUPERIOR|324.45||||324.45||| 9524406|ERX|0250|METHYLERGONOVINE 0.2MG TA|Blue Cross HMO Specialty|BCBSTX HMO|324.45||||||| 9524406|ERX|0250|METHYLERGONOVINE 0.2MG TA|United Healthcare|UNITED HEALTHCARE OTHER|324.45||||||| 9524406|ERX|0250|METHYLERGONOVINE 0.2MG TA|Medicaid|MEDICAID|324.45||||||| 9524448|ERX|0250|CLOZAPINE 100MG TABLET|Medicare|MEDICARE ACUTE|63.25||||||| 9524448|ERX|0250|CLOZAPINE 100MG TABLET|Rusk State Hospital|RUSK STATE HOSP|63.25||||||| 9524554|ERX|0250|CALCITONIN 200 UNITS, 3.7|Medicare|MEDICARE ACUTE|1,300.75||||||| 9524596|ERX|0250|OXCARBAZEPINE 300MG TABLE|Medicare|MEDICARE ACUTE|32.25||||||| 9524596|ERX|0250|OXCARBAZEPINE 300MG TABLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||32.25||| 9524679|ERX|0250|VALSARTAN 80MG TABLET|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|24.50||||||| 9524679|ERX|0250|VALSARTAN 80MG TABLET|Humana Medicare Advantage|HUMANA MA|24.50||||||| 9524679|ERX|0250|VALSARTAN 80MG TABLET|Medicare|MEDICARE ACUTE|24.50||||||| 9524687|ERX|0250|VALSARTAN 160MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||25.50||| 9524687|ERX|0250|VALSARTAN 160MG TABLET|Medicare|MEDICARE ACUTE|25.50||||25.50||| 9524687|ERX|0250|VALSARTAN 160MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|25.50||||||| 9524687|ERX|0250|VALSARTAN 160MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|25.50||||||| 9524802|ERX|0250|DARIFENACIN 7.5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||43.75||| 9524927|ERX|0250|OXCARBAZEPINE 600MG TABLE|Medicare|MEDICARE ACUTE|0.62||||||| 9524927|ERX|0250|OXCARBAZEPINE 600MG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.62||| 9524976|ERX|0250|RIVASTIGMINE 4.6MG PATCH|Humana Medicare Advantage|HUMANA MA|76.50||||||| 9524976|ERX|0250|RIVASTIGMINE 4.6MG PATCH|Medicare|MEDICARE ACUTE|76.50||||||| 9524992|ERX|0250|CARBAMAZEPINE XR 100MG TA|Rusk State Hospital|RUSK STATE HOSP|0.08||||||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|United Healthcare|UNITED HEALTHCARE|3.70||||||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|United Healthcare|UNITED HEALTHCARE OTHER|||||3.70||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.70||||||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Blue Cross HMO Specialty|BCBSTX HMO|3.70||||3.70||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Blue Cross PPO Specialty|BCBSTX PPO|||||3.70||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Cigna|CIGNA|3.70||||||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||3.70||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Managed Medicaid|MEDICAID SUPERIOR|3.70||||3.70||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Managed Medicaid|MEDICAID AMERIGROUP|3.70||||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|3.70||||||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|Medicare|MEDICARE ACUTE|3.70||||||| 9525072|ERX|0250|CELESTONE SOLUSPAN 30MG/5|NON CONTRACTED|COMMERCIAL OTHER 2|3.70||||||| 9525106|ERX|0250|CLOTRIMAZ-BETAMETHASONE|Humana Medicare Advantage|HUMANA MA|386.25||||||| 9525106|ERX|0250|CLOTRIMAZ-BETAMETHASONE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|386.25||||||| 9525106|ERX|0250|CLOTRIMAZ-BETAMETHASONE|Managed Medicaid|MEDICAID AMERIGROUP|386.25||||||| 9525106|ERX|0250|CLOTRIMAZ-BETAMETHASONE|United Medicare Advantage|UHC MEDICARE GOLD MA|386.25||||||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Medicaid|MEDICAID|||||91.50||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|United Healthcare|UNITED HEALTHCARE|||||91.50||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Veterans Affairs|VETERANS ADMINISTRATION|||||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|United Medicare Advantage|AARP UHC WEST COMPLETE MA|91.50||||||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||91.50||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|||||91.50||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|||||91.50||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Humana Medicare Advantage|HUMANA MA|91.50||||91.50||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Cigna|CIGNA|||||91.50||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||91.50||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Managed Medicaid|MEDICAID SUPERIOR|||||91.50||| 9525221|ERX|0250|OSELTAMIVIR 75MG CAPSULE|Managed Medicaid|MEDICAID AMERIGROUP|91.50||||91.50||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|Humana Medicare Advantage|HUMANA MA|323.25||||323.25||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|323.25||||||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|323.25||||||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|Managed Medicaid|MEDICAID SUPERIOR|||||323.25||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||323.25||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||323.25||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|Blue Cross PPO Specialty|BCBSTX PPO|323.25||||323.25||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||323.25||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|323.25||||||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||323.25||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|Medicaid|MEDICAID|323.25||||||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||323.25||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|Medicare|MEDICARE ACUTE|323.25||||323.25||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|NON CONTRACTED|COMMERCIAL OTHER 1|323.25||||||| 9525247|ERX|0250|CIPROFLOXACIN 400MG/200ML|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|323.25||||||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|Medicare|MEDICARE ACUTE|63.75||||63.75||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|NON CONTRACTED|COMMERCIAL OTHER 1|63.75||||||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||63.75||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|Medicaid|MEDICAID|||||63.75||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|United Healthcare|UNITED HEALTHCARE|||||63.75||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|Veterans Affairs|VETERANS ADMINISTRATION|||||63.75||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||63.75||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||63.75||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|Workers Compensation|WORKERS COMPENSATION OTHER|||||63.75||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|Blue Cross PPO Specialty|BCBSTX PPO|||||63.75||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|Aetna|AETNA OTHER|||||63.75||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|Humana Medicare Advantage|HUMANA MA|63.75||||63.75||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|Brinson Benefits|THE HEALTH PLAN SMITH CO|63.75||||||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||63.75||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||63.75||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|Managed Medicaid|MEDICAID SUPERIOR|||||63.75||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|Managed Medicaid|MEDICAID AMERIGROUP|||||63.75||| 9525262|ERX|0250|CIPROFLOXACIN 500MG TABLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|63.75||||63.75||| 9525270|ERX|0250|CIPROFLOXACIN 200MG/100ML|Medicare|MEDICARE ACUTE|189.50||||||| 9525338|ERX|0250|NITROGLYCERIN 0.3MG PATCH|Medicare|MEDICARE ACUTE|41.50||||||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|Humana Medicare Advantage|HUMANA MA|24.50||||||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|24.50||||||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||24.50||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|24.50||||||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|24.50||||24.50||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|24.50||||||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||24.50||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|24.50||||24.50||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||24.50||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|24.50||||||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|Medicare|MEDICARE ACUTE|24.50||||24.50||| 9525429|ERX|0250|BUSPIRONE 10MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|24.50||||||| 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||||||| 9525460|ERX|0250|METFORMIN 500MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.15||||||| 9525460|ERX|0250|METFORMIN 500MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.15||||||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Medicaid|MEDICAID|0.15||||0.15||| 9525460|ERX|0250|METFORMIN 500MG TABLET|United Healthcare|UNITED HEALTHCARE|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||||||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.15||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.15||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.15||||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 CIGNA HEALTHSPRING|0.15||||||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|0.15||||||| 9525460|ERX|0250|METFORMIN 500MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|0.15||||0.15||| 9525486|ERX|0250|METFORMIN XL 500MG TABLET|Humana Medicare Advantage|HUMANA MA|||||0.15||| 9525486|ERX|0250|METFORMIN XL 500MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.15||||||| 9525494|ERX|0250|METFORMIN 850MG TABLET|Medicare|MEDICARE ACUTE|0.23||||||| 9525494|ERX|0250|METFORMIN 850MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.23||||||| 9525494|ERX|0250|METFORMIN 850MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.23||||||| 9525544|ERX|0250|FEXOFENADINE 180MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.29||||||| 9525544|ERX|0250|FEXOFENADINE 180MG TABLET|Workers Compensation|UT EMPLOYEE INJURY|0.29||||||| 9525544|ERX|0250|FEXOFENADINE 180MG TABLET|Humana Medicare Advantage|HUMANA MA|0.29||||||| 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|Rusk State Hospital|RUSK STATE HOSP|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|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|2.50||||||| 9525577|ERX|0250|CALCIUM CARB 500 W/VIT D|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2.50||| 9525585|ERX|0250|LEFLUNOMIDE 20MG TABLET|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|212.25||||||| 9525585|ERX|0250|LEFLUNOMIDE 20MG TABLET|Humana Medicare Advantage|HUMANA MA|212.25||||||| 9525585|ERX|0250|LEFLUNOMIDE 20MG TABLET|Medicare|MEDICARE ACUTE|212.25||||||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|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|Rusk State Hospital|RUSK STATE HOSP|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|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.56||||0.56||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Aenta Medicare Advantage|AETNA MEDICARE MA|0.56||||||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Blue Cross HMO Specialty|BCBSTX HMO|0.56||||||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Blue Cross PPO Specialty|BCBSTX PPO|0.56||||||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Blue Cross PPO Specialty|BCBSTX OTHER|0.56||||||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|NON CONTRACTED|COMMERCIAL OTHER 1|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|Brinson Benefits|THE HEALTH PLAN SMITH CO|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|United Healthcare|UMR UNITED MEDICAL RESOURCES|0.56||||||| 9525593|ERX|0250|LANTUS 100 UNIT/1ML,10ML|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|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||| 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|Workers Compensation|UT EMPLOYEE INJURY|0.56||||||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Workers Compensation|WORKERS COMPENSATION OTHER|||||2.78||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|United Healthcare|UNITED HEALTHCARE|||||2.78||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Veterans Affairs|VETERANS ADMINISTRATION|||||2.78||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||2.78||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||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|Humana Medicare Advantage|HUMANA MA|||||2.78||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Managed Medicaid|MEDICAID SUPERIOR|||||2.78||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2.78||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||2.78||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||2.78||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.78||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Blue Cross HMO Specialty|BCBSTX HMO|||||2.78||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Blue Cross PPO Specialty|BCBSTX PPO|||||2.78||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Blue Cross PPO Specialty|BCBSTX OTHER|||||2.78||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|Medicare|MEDICARE ACUTE|||||2.78||| 9525627|ERX|0250|ORPHENADRINE 60MG/2ML|NON CONTRACTED|COMMERCIAL OTHER 1|||||2.78||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Medicaid|MEDICAID|163.75||||163.75||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Medicaid|MEDICAID TEXAS CHILDRENS|||||163.75||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Medicare|MEDICARE ACUTE|163.75||||163.75||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Rusk State Hospital|RUSK STATE HOSP|163.75||||163.75||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||163.75||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|163.75||||163.75||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Blue Cross HMO Specialty|BCBSTX HMO|163.75||||163.75||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Aetna|AETNA OTHER|||||163.75||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||163.75||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Blue Cross PPO Specialty|BCBSTX PPO|163.75||||163.75||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Humana Medicare Advantage|HUMANA MA|163.75||||163.75||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|163.75||||163.75||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Cigna|CIGNA|||||163.75||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||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||||163.75||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|Managed Medicaid|MEDICAID SUPERIOR|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|United Healthcare|UNITED HEALTHCARE|||||163.75||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||163.75||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|163.75||||163.75||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||163.75||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|||||163.75||| 9525676|ERX|0250|CEFTRIAXONE 1 G VIAL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||163.75||| 9525718|ERX|0250|HYOSCYAMINE 0.125MG/ML, 1|Humana Medicare Advantage|HUMANA MA|||||466.25||| 9525718|ERX|0250|HYOSCYAMINE 0.125MG/ML, 1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|466.25||||||| 9525775|ERX|0250|NORTRIPTYLINE 25MG CAPSUL|Blue Cross HMO Specialty|BCBSTX HMO|||||11.75||| 9525783|ERX|0250|KETOCONAZOLE 2% CREAM, 15|Humana Medicare Advantage|HUMANA MA|162.75||||||| 9525890|ERX|0250|AMOXICILLIN 250MG/5ML,100|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||60.75||| 9525890|ERX|0250|AMOXICILLIN 250MG/5ML,100|Managed Medicaid|MEDICAID SUPERIOR|||||60.75||| 9525890|ERX|0250|AMOXICILLIN 250MG/5ML,100|Managed Medicaid|MEDICAID AMERIGROUP|||||60.75||| 9525999|ERX|0250|VENLAFAXINE 75MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|24.50||||||| 9525999|ERX|0250|VENLAFAXINE 75MG TABLET|Humana Medicare Advantage|HUMANA MA|24.50||||||| 9526088|ERX|0250|TERBUTALINE 2.5MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|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 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|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||7.50||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Aenta Medicare Advantage|AETNA MEDICARE MA|7.50||||||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Blue Cross HMO Specialty|BCBSTX HMO|||||7.50||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|7.50||||||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Veterans Affairs|VETERANS ADMINISTRATION|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|Humana Medicare Advantage|HUMANA MA|7.50||||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 UNITED HEALTHCARE|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 AMERIGROUP|||||7.50||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Medicaid|MEDICAID|||||7.50||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||7.50||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Medicaid|MEDICAID HMO|||||7.50||| 9526104|ERX|0250|MAG HYDROX 400MG/5ML,30ML|Medicare|MEDICARE ACUTE|7.50||||7.50||| 9526112|ERX|0250|MINERAL OIL 30ML|Medicare|MEDICARE ACUTE|0.09||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|Humana Medicare Advantage|HUMANA MA|2.50||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|Managed Medicaid|MEDICAID SUPERIOR|||||2.50||| 9526161|ERX|0250|MELATONIN 3MG TAB|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.50||| 9526161|ERX|0250|MELATONIN 3MG TAB|Aenta Medicare Advantage|AETNA MEDICARE MA|2.50||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|United Medicare Advantage|AARP UHC WEST COMPLETE MA|2.50||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|United Medicare Advantage|UHC MEDICARE GOLD MA|||||2.50||| 9526161|ERX|0250|MELATONIN 3MG TAB|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.50||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.50||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|Medicaid|MEDICAID|2.50||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|Medicare|MEDICARE ACUTE|2.50||||2.50||| 9526161|ERX|0250|MELATONIN 3MG TAB|Rusk State Hospital|RUSK STATE HOSP|2.50||||||| 9526161|ERX|0250|MELATONIN 3MG TAB|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.50||||||| 9526179|ERX|0250|DIPHENHYDRAMINE ELIX 25MG|Medicare|MEDICARE ACUTE|||||0.07||| 9526179|ERX|0250|DIPHENHYDRAMINE ELIX 25MG|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.07||| 9526179|ERX|0250|DIPHENHYDRAMINE ELIX 25MG|Managed Medicare|HEALTHSPRING MA|||||0.07||| 9526179|ERX|0250|DIPHENHYDRAMINE ELIX 25MG|Medicaid|MEDICAID TEXAS CHILDRENS|||||0.07||| 9526179|ERX|0250|DIPHENHYDRAMINE ELIX 25MG|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||0.07||| 9526179|ERX|0250|DIPHENHYDRAMINE ELIX 25MG|Tricare|TRICARE EAST REGION|||||0.07||| 9526179|ERX|0250|DIPHENHYDRAMINE ELIX 25MG|Medicaid|MEDICAID HMO|||||0.07||| 9526179|ERX|0250|DIPHENHYDRAMINE ELIX 25MG|Medicaid|MEDICAID|||||0.07||| 9526179|ERX|0250|DIPHENHYDRAMINE ELIX 25MG|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.07||| 9526179|ERX|0250|DIPHENHYDRAMINE ELIX 25MG|Blue Cross HMO Specialty|BCBSTX HMO|||||0.07||| 9526179|ERX|0250|DIPHENHYDRAMINE ELIX 25MG|Blue Cross PPO Specialty|BCBSTX PPO|||||0.07||| 9526179|ERX|0250|DIPHENHYDRAMINE ELIX 25MG|Humana Medicare Advantage|HUMANA MA|0.07||||||| 9526179|ERX|0250|DIPHENHYDRAMINE ELIX 25MG|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||0.07||| 9526179|ERX|0250|DIPHENHYDRAMINE ELIX 25MG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.07||||0.07||| 9526179|ERX|0250|DIPHENHYDRAMINE ELIX 25MG|Managed Medicaid|MEDICAID SUPERIOR|0.07||||0.07||| 9526179|ERX|0250|DIPHENHYDRAMINE ELIX 25MG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.07||| 9526179|ERX|0250|DIPHENHYDRAMINE ELIX 25MG|Managed Medicaid|MEDICAID AMERIGROUP|||||0.07||| 9526187|ERX|0250|QUETIAPINE 300MG TABLET|Medicare|MEDICARE ACUTE|118.75||||||| 9526252|ERX|0250|CLONIDINE 0.3MG TABLET|Medicare|MEDICARE ACUTE|25.25||||||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|United Healthcare|UNITED HEALTHCARE|11.75||||11.75||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Veterans Affairs|VETERANS ADMINISTRATION|11.75||||11.75||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|United Medicare Advantage|UHC MEDICARE GOLD MA|11.75||||||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|11.75||||11.75||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|United Medicare Advantage|AARP UHC WEST COMPLETE MA|11.75||||||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Humana Medicare Advantage|HUMANA MA|11.75||||11.75||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Cigna|CIGNA|11.75||||11.75||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Managed Medicaid|MEDICAID UNITED HEALTHCARE|11.75||||11.75||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Managed Medicaid|MEDICAID SUPERIOR|11.75||||11.75||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||11.75||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Managed Medicaid|MEDICAID AMERIGROUP|11.75||||11.75||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Blue Cross HMO Specialty|BCBSTX HMO|11.75||||||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||11.75||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|11.75||||11.75||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||11.75||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Blue Cross PPO Specialty|BCBSTX PPO|11.75||||11.75||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|11.75||||11.75||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Managed Medicare|WELLCARE CHOICE MA|||||11.75||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Managed Medicare|HEALTHSPRING MA|11.75||||||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Medicaid|MEDICAID TEXAS CHILDRENS|||||11.75||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Medicaid|MEDICAID|11.75||||11.75||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||11.75||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Medicare|MEDICARE ACUTE|11.75||||11.75||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|NON CONTRACTED|COMMERCIAL OTHER 1|11.75||||11.75||| 9526302|ERX|0250|SODIUM CHLORIDE INHALANT,|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||11.75||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.07||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|Managed Medicaid|MEDICAID AMERIGROUP|||||0.07||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|Cigna|CIGNA|||||0.07||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||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 SUPERIOR|0.07||||0.07||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|United Healthcare|UNITED HEALTHCARE|||||0.07||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|Medicaid|MEDICAID HMO|||||0.07||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.07||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||0.07||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|Blue Cross PPO Specialty|BCBSTX PPO|0.07||||0.07||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|Medicaid|MEDICAID|0.07||||0.07||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|Medicaid|MEDICAID TEXAS CHILDRENS|||||0.07||| 9526310|ERX|0250|ACETAMINOPHEN 160MG/5ML C|Medicaid|SUPERIOR HEALTHPLAN CHIP|0.07||||0.07||| 9526336|ERX|0250|CEFAZOLIN 1 GM/100 ML MB+|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||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+|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.22||||0.22||| 9526336|ERX|0250|CEFAZOLIN 1 GM/100 ML MB+|NON CONTRACTED|COMMERCIAL OTHER 1|0.22||||0.22||| 9526336|ERX|0250|CEFAZOLIN 1 GM/100 ML MB+|Medicare|MEDICARE PART B ONLY IP|||||0.22||| 9526336|ERX|0250|CEFAZOLIN 1 GM/100 ML MB+|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||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+|Blue Cross HMO Specialty|BCBSTX HMO|0.22||||0.22||| 9526336|ERX|0250|CEFAZOLIN 1 GM/100 ML MB+|Medicaid|MEDICAID|0.22||||0.22||| 9526336|ERX|0250|CEFAZOLIN 1 GM/100 ML MB+|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.22||||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+|Managed Medicaid|MEDICAID UNITED HEALTHCARE|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+|Access Direct Platinum|HEALTHFIRST TPA UMR|||||0.22||| 9526336|ERX|0250|CEFAZOLIN 1 GM/100 ML MB+|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||0.22||| 9526336|ERX|0250|CEFAZOLIN 1 GM/100 ML MB+|Aetna|AETNA PPO|||||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+|Humana Medicare Advantage|HUMANA MA|0.22||||0.22||| 9526336|ERX|0250|CEFAZOLIN 1 GM/100 ML MB+|Aenta Medicare Advantage|AETNA MEDICARE MA|0.22||||0.22||| 9526336|ERX|0250|CEFAZOLIN 1 GM/100 ML MB+|Managed Medicaid|MEDICAID AMERIGROUP|0.22||||0.22||| 9526336|ERX|0250|CEFAZOLIN 1 GM/100 ML MB+|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.22||| 9526336|ERX|0250|CEFAZOLIN 1 GM/100 ML MB+|Aetna|AETNA OTHER|||||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 Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.22||| 9526336|ERX|0250|CEFAZOLIN 1 GM/100 ML MB+|Tricare|TRICARE EAST REGION|0.22||||||| 9526336|ERX|0250|CEFAZOLIN 1 GM/100 ML MB+|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||0.22||| 9526336|ERX|0250|CEFAZOLIN 1 GM/100 ML MB+|United Healthcare|UNITED HEALTHCARE OTHER|||||0.22||| 9526336|ERX|0250|CEFAZOLIN 1 GM/100 ML MB+|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.22||||0.22||| 9526336|ERX|0250|CEFAZOLIN 1 GM/100 ML MB+|Managed Medicaid|MEDICAID SUPERIOR|0.22||||0.22||| 9526401|ERX|0250|SILVER NITRATE STK 10CT.|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||0.28||| 9526401|ERX|0250|SILVER NITRATE STK 10CT.|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.28||| 9526401|ERX|0250|SILVER NITRATE STK 10CT.|Managed Medicaid|MEDICAID SUPERIOR|||||0.28||| 9526401|ERX|0250|SILVER NITRATE STK 10CT.|Medicare|MEDICARE ACUTE|||||0.28||| 9526534|ERX|0250|NON-FORMULARY DRUG|Tricare|TRICARE EAST REGION|0.31||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.31||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.31||||0.31||| 9526534|ERX|0250|NON-FORMULARY DRUG|Brinson Benefits|THE HEALTH PLAN SMITH CO|0.31||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.31||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|Aenta Medicare Advantage|AETNA MEDICARE MA|0.31||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|Managed Medicare|HEALTHSPRING MA|0.31||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.31||||0.31||| 9526534|ERX|0250|NON-FORMULARY DRUG|Blue Cross HMO Specialty|BCBSTX HMO|0.31||||0.31||| 9526534|ERX|0250|NON-FORMULARY DRUG|Humana Medicare Advantage|HUMANA MA|0.31||||0.31||| 9526534|ERX|0250|NON-FORMULARY DRUG|Rusk State Hospital|RUSK STATE HOSP|0.31||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|NON CONTRACTED|COMMERCIAL OTHER 1|0.31||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|Managed Medicaid|MEDICAID SUPERIOR|0.31||||||| 9526534|ERX|0250|NON-FORMULARY DRUG|Medicare|MEDICARE ACUTE|0.31||||0.31||| 9526534|ERX|0250|NON-FORMULARY DRUG|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.31||||0.31||| 9526534|ERX|0250|NON-FORMULARY DRUG|Medicaid|MEDICAID|0.31||||||| 9526633|ERX|0250|AVITENE SHEET 70X35X1MM|Medicare|MEDICARE ACUTE|908.75||||||| 9526674|ERX|0636|FONDAPARINUX 5 MG/0.4 ML|Medicare|MEDICARE ACUTE|808.75||||||| 9526716|ERX|0250|0.45% SODIUM CHLORIDE KCL|Aetna|AETNA OTHER|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|Medicare|MEDICARE ACUTE|2.10||||||| 9526716|ERX|0250|0.45% SODIUM CHLORIDE KCL|Humana Medicare Advantage|HUMANA MA|2.10||||||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Managed Medicaid|MEDICAID SUPERIOR|13.75||||13.75||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Blue Cross PPO Specialty|BCBSTX PPO|||||13.75||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Humana Medicare Advantage|HUMANA MA|13.75||||||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Managed Medicaid|MEDICAID AMERIGROUP|||||13.75||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Rusk State Hospital|RUSK STATE HOSP|13.75||||||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Veterans Affairs|VETERANS ADMINISTRATION|13.75||||||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|UTMB|UTMB CORRECTIONAL MANAGED CARE|13.75||||||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Blue Cross HMO Specialty|BCBSTX HMO|13.75||||||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|13.75||||||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Aenta Medicare Advantage|AETNA MEDICARE MA|13.75||||||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|United Medicare Advantage|AARP UHC WEST COMPLETE MA|13.75||||||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Medicaid|MEDICAID TEXAS CHILDRENS|||||13.75||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Medicaid|MEDICAID|||||13.75||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Managed Medicaid|MEDICAID UNITED HEALTHCARE|13.75||||||| 9526765|ERX|0250|ACETAMINOPHEN 650 MG/20.3|Medicare|MEDICARE ACUTE|13.75||||13.75||| 9526773|ERX|0250|RIVAROXABAN 10 MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|61.50||||61.50||| 9526773|ERX|0250|RIVAROXABAN 10 MG TABLET|Veterans Affairs|VETERANS ADMINISTRATION|61.50||||||| 9526773|ERX|0250|RIVAROXABAN 10 MG TABLET|Medicaid|MEDICAID|61.50||||||| 9526773|ERX|0250|RIVAROXABAN 10 MG TABLET|Humana Medicare Advantage|HUMANA MA|61.50||||||| 9526773|ERX|0250|RIVAROXABAN 10 MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|61.50||||||| 9526773|ERX|0250|RIVAROXABAN 10 MG TABLET|Medicare|MEDICARE ACUTE|61.50||||||| 9526773|ERX|0250|RIVAROXABAN 10 MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|61.50||||61.50||| 9526773|ERX|0250|RIVAROXABAN 10 MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||61.50||| 9526773|ERX|0250|RIVAROXABAN 10 MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|61.50||||||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||11.75||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|United Medicare Advantage|UHC MEDICARE GOLD MA|||||11.75||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||11.75||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|Medicare|MEDICARE ACUTE|11.75||||11.75||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||11.75||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||11.75||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|Blue Cross PPO Specialty|BCBSTX PPO|||||11.75||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|Managed Medicaid|MEDICAID AMERIGROUP|||||11.75||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|11.75||||11.75||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||11.75||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|Humana Medicare Advantage|HUMANA MA|||||11.75||| 9526781|ERX|0250|HEPARIN 100UNIT/ML 5 ML|Blue Cross HMO Specialty|BCBSTX HMO|||||11.75||| 9526807|ERX|0250|HYDROCORTISONE 2.5% CREAM|Humana Medicare Advantage|HUMANA MA|83.75||||||| 9526807|ERX|0250|HYDROCORTISONE 2.5% CREAM|Managed Medicaid|MEDICAID AMERIGROUP|83.75||||||| 9526831|ERX|0250|TICAGRELOR 90 MG TABLET|Medicare|MEDICARE ACUTE|40.25||||||| 9526914|ERX|0250||Aenta Medicare Advantage|AETNA MEDICARE MA|152.25||||||| 9526914|ERX|0250||United Healthcare|UNITED HEALTHCARE|152.25||||||| 9526914|ERX|0250||Blue Cross PPO Specialty|BCBSTX PPO|152.25||||||| 9526914|ERX|0250||Managed Medicaid|MEDICAID AMERIGROUP|152.25||||152.25||| 9526914|ERX|0250||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|152.25||||||| 9526914|ERX|0250||Cigna|CIGNA|152.25||||||| 9526914|ERX|0250||Blue Cross HMO Specialty|BCBSTX HMO|152.25||||||| 9526914|ERX|0250||United Medicare Advantage|UHC MEDICARE GOLD MA|152.25||||||| 9526914|ERX|0250||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|152.25||||||| 9526914|ERX|0250||United Healthcare|UMR UNITED MEDICAL RESOURCES|152.25||||||| 9526914|ERX|0250||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|152.25||||152.25||| 9526914|ERX|0250||Rusk State Hospital|RUSK STATE HOSP|152.25||||||| 9526914|ERX|0250||Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|152.25||||||| 9526914|ERX|0250||Medicare|MEDICARE PART B ONLY IP|152.25||||||| 9526914|ERX|0250||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|152.25||||||| 9526914|ERX|0250||Medicare|MEDICARE ACUTE|152.25||||152.25||| 9526914|ERX|0250||NON CONTRACTED|COMMERCIAL OTHER 1|152.25||||||| 9526914|ERX|0250||Medicaid|MEDICAID|152.25||||152.25||| 9526914|ERX|0250||Managed Medicaid|MEDICAID UNITED HEALTHCARE|152.25||||||| 9526914|ERX|0250||UTMB|UTMB CORRECTIONAL MANAGED CARE|152.25||||||| 9526914|ERX|0250||Humana Medicare Advantage|HUMANA MA|152.25||||152.25||| 9526914|ERX|0250||Medicaid|MOLINA HEALTHCARE OF TEXAS|152.25||||||| 9526914|ERX|0250||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|152.25||||||| 9526914|ERX|0250||Managed Medicaid|MEDICAID SUPERIOR|152.25||||152.25||| 9526930|ERX|0636|FONDAPARINUX 10 MG/0.8 ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|808.75||||||| 9526948|ERX|0250|RIVAROXABAN 15MG TABLET|Medicare|MEDICARE ACUTE|0.57||||||| 9526948|ERX|0250|RIVAROXABAN 15MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.57||| 9526948|ERX|0250|RIVAROXABAN 15MG TABLET|Humana Medicare Advantage|HUMANA MA|0.57||||0.57||| 9526948|ERX|0250|RIVAROXABAN 15MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.57||||0.57||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Aetna|AETNA PPO|||||0.19||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|United Medicare Advantage|UHC MEDICARE SOLUTIONS 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|MEDICARE ADVANTAGE OTHER MA|0.19||||0.19||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Medicaid|MEDICAID|0.19||||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|United Healthcare|UNITED HEALTHCARE|||||0.19||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Rusk State Hospital|RUSK STATE HOSP|0.19||||0.19||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Tricare|TRICARE EAST REGION|||||0.19||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.19||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.19||||0.19||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Managed Medicare|HOSPICE OF EAST TEXAS|0.19||||||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Veterans Affairs|VETERANS ADMINISTRATION|0.19||||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|Aenta Medicare Advantage|AETNA MEDICARE 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|NON CONTRACTED|COMMERCIAL OTHER 1|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|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.19||||0.19||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.19||||0.19||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Medicaid|MEDICAID TEXAS CHILDRENS|||||0.19||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|United Healthcare|UNITED HEALTHCARE|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|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.19||||0.19||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|United Healthcare|UMR UNITED MEDICAL RESOURCES|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|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|Cigna|CIGNA|||||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|Humana Medicare Advantage|HUMANA MA|0.19||||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|Managed Medicaid|MEDICAID AMERIGROUP|0.19||||0.19||| 9527078|ERX|0250|ALBUTER 3MG / IPRATR. 0.5|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.19||| 9527169|ERX|0250|CEFDINIR (OMNICEF) 125MG/|Managed Medicaid|MEDICAID SUPERIOR|3.10||||3.10||| 9527169|ERX|0250|CEFDINIR (OMNICEF) 125MG/|Medicaid|MEDICAID TEXAS CHILDRENS|||||3.10||| 9527169|ERX|0250|CEFDINIR (OMNICEF) 125MG/|Medicaid|MEDICAID|3.10||||||| 9527169|ERX|0250|CEFDINIR (OMNICEF) 125MG/|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.10||||||| 9527250|ERX|0250|FELODIPINE 5MG TABLET|Humana Medicare Advantage|HUMANA MA|0.13||||||| 9527250|ERX|0250|FELODIPINE 5MG TABLET|Medicare|MEDICARE ACUTE|0.13||||||| 9527300|ERX|0250|PHENAZOPYRIDINE 200MG TAB|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.11||| 9527300|ERX|0250|PHENAZOPYRIDINE 200MG TAB|Blue Cross PPO Specialty|BCBSTX PPO|||||0.11||| 9527300|ERX|0250|PHENAZOPYRIDINE 200MG TAB|Humana Medicare Advantage|HUMANA MA|||||0.11||| 9527300|ERX|0250|PHENAZOPYRIDINE 200MG TAB|Medicaid|MEDICAID|||||0.11||| 9527300|ERX|0250|PHENAZOPYRIDINE 200MG TAB|Medicare|MEDICARE ACUTE|0.11||||0.11||| 9527300|ERX|0250|PHENAZOPYRIDINE 200MG TAB|Managed Medicaid|MEDICAID SUPERIOR|||||0.11||| 9527300|ERX|0250|PHENAZOPYRIDINE 200MG TAB|Blue Cross HMO Specialty|BCBSTX HMO|||||0.11||| 9527318|ERX|0250|VANCOMYCIN 125MG CAPSULE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|163.50||||||| 9527318|ERX|0250|VANCOMYCIN 125MG CAPSULE|Medicare|MEDICARE ACUTE|163.50||||||| 9527318|ERX|0250|VANCOMYCIN 125MG CAPSULE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|163.50||||||| 9527417|ERX|0250|ROFLUMILAST 500MG TABLET|Medicare|MEDICARE ACUTE|48.50||||||| 9527417|ERX|0250|ROFLUMILAST 500MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|48.50||||||| 9527417|ERX|0250|ROFLUMILAST 500MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|48.50||||||| 9527417|ERX|0250|ROFLUMILAST 500MG TABLET|Managed Medicare|HEALTHSPRING MA|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|Managed Medicaid|MEDICAID UNITED HEALTHCARE|48.50||||||| 9527425|ERX|0250|SEVOFLURANE TOPICAL SPRAY|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1,178.50||| 9527425|ERX|0250|SEVOFLURANE TOPICAL SPRAY|United Healthcare|UNITED HEALTHCARE OTHER|1,178.50||||1,178.50||| 9527425|ERX|0250|SEVOFLURANE TOPICAL SPRAY|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|1,178.50||||1,178.50||| 9527425|ERX|0250|SEVOFLURANE TOPICAL SPRAY|United Medicare Advantage|UHC MEDICARE GOLD MA|1,178.50||||1,178.50||| 9527425|ERX|0250|SEVOFLURANE TOPICAL SPRAY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,178.50||||1,178.50||| 9527425|ERX|0250|SEVOFLURANE TOPICAL SPRAY|Workers Compensation|WORKERS COMPENSATION OTHER|1,178.50||||1,178.50||| 9527425|ERX|0250|SEVOFLURANE TOPICAL SPRAY|Tricare|TRICARE EAST REGION|||||1,178.50||| 9527425|ERX|0250|SEVOFLURANE TOPICAL SPRAY|Managed Medicare|HEALTHSPRING MA|||||1,178.50||| 9527425|ERX|0250|SEVOFLURANE TOPICAL SPRAY|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1,178.50||| 9527425|ERX|0250|SEVOFLURANE TOPICAL SPRAY|United Healthcare|UNITED HEALTHCARE|||||1,178.50||| 9527425|ERX|0250|SEVOFLURANE TOPICAL SPRAY|Brinson Benefits|THE HEALTH PLAN SMITH CO|1,178.50||||||| 9527425|ERX|0250|SEVOFLURANE TOPICAL SPRAY|Humana Medicare Advantage|HUMANA MA|1,178.50||||1,178.50||| 9527425|ERX|0250|SEVOFLURANE TOPICAL SPRAY|Medicare|MEDICARE ACUTE|1,178.50||||1,178.50||| 9527425|ERX|0250|SEVOFLURANE TOPICAL SPRAY|Medicaid|MEDICAID|1,178.50||||1,178.50||| 9527425|ERX|0250|SEVOFLURANE TOPICAL SPRAY|Managed Medicaid|MEDICAID SUPERIOR|1,178.50||||1,178.50||| 9527425|ERX|0250|SEVOFLURANE TOPICAL SPRAY|United Medicare Advantage|AARP UHC WEST COMPLETE MA|1,178.50||||1,178.50||| 9527425|ERX|0250|SEVOFLURANE TOPICAL SPRAY|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1,178.50||||1,178.50||| 9527425|ERX|0250|SEVOFLURANE TOPICAL SPRAY|NON CONTRACTED|COMMERCIAL OTHER 1|1,178.50||||1,178.50||| 9527425|ERX|0250|SEVOFLURANE TOPICAL SPRAY|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,178.50||||1,178.50||| 9527425|ERX|0250|SEVOFLURANE TOPICAL SPRAY|Managed Medicaid|MEDICAID AMERIGROUP|1,178.50||||1,178.50||| 9527425|ERX|0250|SEVOFLURANE TOPICAL SPRAY|Veterans Affairs|VETERANS ADMINISTRATION|||||1,178.50||| 9527425|ERX|0250|SEVOFLURANE TOPICAL SPRAY|Aenta Medicare Advantage|AETNA MEDICARE MA|1,178.50||||1,178.50||| 9527425|ERX|0250|SEVOFLURANE TOPICAL SPRAY|Access Direct Platinum|HEALTHFIRST TPA UMR|||||1,178.50||| 9527425|ERX|0250|SEVOFLURANE TOPICAL SPRAY|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,178.50||| 9527425|ERX|0250|SEVOFLURANE TOPICAL SPRAY|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|1,178.50||||||| 9527425|ERX|0250|SEVOFLURANE TOPICAL SPRAY|Aetna|AETNA OTHER|||||1,178.50||| 9527425|ERX|0250|SEVOFLURANE TOPICAL SPRAY|Aetna|AETNA PPO|||||1,178.50||| 9527425|ERX|0250|SEVOFLURANE TOPICAL SPRAY|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,178.50||||1,178.50||| 9527425|ERX|0250|SEVOFLURANE TOPICAL SPRAY|Blue Cross PPO Specialty|BCBSTX PPO|1,178.50||||1,178.50||| 9527425|ERX|0250|SEVOFLURANE TOPICAL SPRAY|Managed Medicare|BCBS MEDICARE PPO MA|||||1,178.50||| 9527425|ERX|0250|SEVOFLURANE TOPICAL SPRAY|Blue Cross HMO Specialty|BCBSTX HMO|1,178.50||||1,178.50||| 9527425|ERX|0250|SEVOFLURANE TOPICAL SPRAY|Blue Cross PPO Specialty|BCBSTX OTHER|||||1,178.50||| 9527425|ERX|0250|SEVOFLURANE TOPICAL SPRAY|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1,178.50||||1,178.50||| 9527433|ERX|0250|ALFUZOSIN ER 10MG TABLET|Medicare|MEDICARE ACUTE|35.50||||35.50||| 9527441|ERX|0250|MOXIFLOXACIN 0.5% EYE DRO|United Healthcare|UNITED HEALTHCARE|||||533.50||| 9527441|ERX|0250|MOXIFLOXACIN 0.5% EYE DRO|Medicare|MEDICARE ACUTE|||||533.50||| 9527458|ERX|0250|FENOFIBRATE 145MG TABLET|Workers Compensation|WORKERS COMPENSATION OTHER|44.75||||||| 9527458|ERX|0250|FENOFIBRATE 145MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|44.75||||||| 9527458|ERX|0250|FENOFIBRATE 145MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|44.75||||||| 9527458|ERX|0250|FENOFIBRATE 145MG TABLET|Humana Medicare Advantage|HUMANA MA|44.75||||||| 9527458|ERX|0250|FENOFIBRATE 145MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|44.75||||||| 9527458|ERX|0250|FENOFIBRATE 145MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||44.75||| 9527524|ERX|0250|HYDROGEN PEROXIDE 3%, 4OZ|Blue Cross PPO Specialty|BCBSTX PPO|||||0.11||| 9527532|ERX|0250|LIDOCAINE + EPINEPHRINE 1|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||103.25||| 9527532|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Medicare|MEDICARE ACUTE|||||103.25||| 9527532|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Workers Compensation|WORKERS COMPENSATION OTHER|||||103.25||| 9527532|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Veterans Affairs|VETERANS ADMINISTRATION|||||103.25||| 9527532|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||103.25||| 9527532|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||103.25||| 9527532|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Managed Medicaid|MEDICAID AMERIGROUP|||||103.25||| 9527532|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Blue Cross HMO Specialty|BCBSTX HMO|||||103.25||| 9527532|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Humana Medicare Advantage|HUMANA MA|||||103.25||| 9527532|ERX|0250|LIDOCAINE + EPINEPHRINE 1|United Healthcare|UNITED HEALTHCARE|||||103.25||| 9527532|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Managed Medicaid|MEDICAID SUPERIOR|||||103.25||| 9527540|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Aenta Medicare Advantage|AETNA MEDICARE MA|103.25||||103.25||| 9527540|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||103.25||| 9527540|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Blue Cross HMO Specialty|BCBSTX HMO|||||103.25||| 9527540|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||103.25||| 9527540|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||103.25||| 9527540|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Blue Cross PPO Specialty|BCBSTX PPO|||||103.25||| 9527540|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Medicaid|MEDICAID|||||103.25||| 9527540|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||103.25||| 9527540|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Medicare|MEDICARE ACUTE|||||103.25||| 9527540|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||103.25||| 9527540|ERX|0250|LIDOCAINE + EPINEPHRINE 1|NON CONTRACTED|COMMERCIAL OTHER 1|||||103.25||| 9527540|ERX|0250|LIDOCAINE + EPINEPHRINE 1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||103.25||| 9527557|ERX|0250|LIDOCAINE + EPINEPHRINE 2|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||103.25||| 9527557|ERX|0250|LIDOCAINE + EPINEPHRINE 2|Managed Medicaid|MEDICAID AMERIGROUP|103.25||||||| 9527557|ERX|0250|LIDOCAINE + EPINEPHRINE 2|Managed Medicaid|MEDICAID SUPERIOR|103.25||||103.25||| 9527557|ERX|0250|LIDOCAINE + EPINEPHRINE 2|Blue Cross PPO Specialty|BCBSTX PPO|103.25||||||| 9527557|ERX|0250|LIDOCAINE + EPINEPHRINE 2|NON CONTRACTED|COMMERCIAL OTHER 1|103.25||||||| 9527557|ERX|0250|LIDOCAINE + EPINEPHRINE 2|United Medicare Advantage|UHC MEDICARE GOLD MA|103.25||||||| 9527557|ERX|0250|LIDOCAINE + EPINEPHRINE 2|Medicaid|MEDICAID|103.25||||||| 9527557|ERX|0250|LIDOCAINE + EPINEPHRINE 2|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||103.25||| 9527565|ERX|0250|MAGNESIUM SULFATE 1G/100M|Aenta Medicare Advantage|AETNA MEDICARE MA|103.25||||||| 9527565|ERX|0250|MAGNESIUM SULFATE 1G/100M|United Medicare Advantage|UHC MEDICARE GOLD MA|103.25||||||| 9527565|ERX|0250|MAGNESIUM SULFATE 1G/100M|Managed Medicaid|MEDICAID SUPERIOR|103.25||||||| 9527565|ERX|0250|MAGNESIUM SULFATE 1G/100M|Blue Cross PPO Specialty|BCBSTX PPO|103.25||||||| 9527565|ERX|0250|MAGNESIUM SULFATE 1G/100M|Humana Medicare Advantage|HUMANA MA|103.25||||||| 9527565|ERX|0250|MAGNESIUM SULFATE 1G/100M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|103.25||||||| 9527565|ERX|0250|MAGNESIUM SULFATE 1G/100M|Medicare|MEDICARE ACUTE|103.25||||103.25||| 9527565|ERX|0250|MAGNESIUM SULFATE 1G/100M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|103.25||||||| 9527565|ERX|0250|MAGNESIUM SULFATE 1G/100M|Medicaid|MEDICAID|103.25||||103.25||| 9527565|ERX|0250|MAGNESIUM SULFATE 1G/100M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|103.25||||||| 9527565|ERX|0250|MAGNESIUM SULFATE 1G/100M|NON CONTRACTED|COMMERCIAL OTHER 1|103.25||||||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|Medicare|MEDICARE ACUTE|41.75||||||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|Managed Medicare|HEALTHSPRING MA|41.75||||||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|41.75||||||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||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||||41.75||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|||||41.75||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|Aetna|AETNA OTHER|41.75||||||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|41.75||||||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|41.75||||||| 9527581|ERX|0250|PRAVASTATIN 20 MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|41.75||||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|MEDICARE ADVANTAGE OTHER MA|41.75||||||| 9527664|ERX|0250|AZITHROMYCIN 500MG/250ML|Humana Medicare Advantage|HUMANA MA|2.09||||||| 9527664|ERX|0250|AZITHROMYCIN 500MG/250ML|Aenta Medicare Advantage|AETNA MEDICARE MA|2.09||||||| 9527664|ERX|0250|AZITHROMYCIN 500MG/250ML|Managed Medicaid|MEDICAID AMERIGROUP|2.09||||||| 9527664|ERX|0250|AZITHROMYCIN 500MG/250ML|Blue Cross HMO Specialty|BCBSTX HMO|2.09||||||| 9527664|ERX|0250|AZITHROMYCIN 500MG/250ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|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 PPO Specialty|BCBSTX OTHER|2.09||||||| 9527664|ERX|0250|AZITHROMYCIN 500MG/250ML|Veterans Affairs|VETERANS ADMINISTRATION|2.09||||||| 9527664|ERX|0250|AZITHROMYCIN 500MG/250ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|2.09||||2.09||| 9527664|ERX|0250|AZITHROMYCIN 500MG/250ML|Managed Medicaid|MEDICAID SUPERIOR|2.09||||2.09||| 9527664|ERX|0250|AZITHROMYCIN 500MG/250ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|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|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.09||||||| 9527664|ERX|0250|AZITHROMYCIN 500MG/250ML|Medicare|MEDICARE ACUTE|2.09||||2.09||| 9527664|ERX|0250|AZITHROMYCIN 500MG/250ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.09||||||| 9527664|ERX|0250|AZITHROMYCIN 500MG/250ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||2.09||| 9527664|ERX|0250|AZITHROMYCIN 500MG/250ML|NON CONTRACTED|COMMERCIAL OTHER 1|2.09||||||| 9527664|ERX|0250|AZITHROMYCIN 500MG/250ML|Rusk State Hospital|RUSK STATE HOSP|2.09||||||| 9527664|ERX|0250|AZITHROMYCIN 500MG/250ML|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|2.09||||||| 9527664|ERX|0250|AZITHROMYCIN 500MG/250ML|United Medicare Advantage|UHC MEDICARE GOLD MA|2.09||||2.09||| 9527672|ERX|0250|AZTREONAM 1G/100ML NS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|247.75||||||| 9527672|ERX|0250|AZTREONAM 1G/100ML NS|Rusk State Hospital|RUSK STATE HOSP|247.75||||||| 9527672|ERX|0250|AZTREONAM 1G/100ML NS|Humana Medicare Advantage|HUMANA MA|247.75||||||| 9527672|ERX|0250|AZTREONAM 1G/100ML NS|Medicare|MEDICARE ACUTE|247.75||||||| 9527672|ERX|0250|AZTREONAM 1G/100ML NS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|247.75||||||| 9527672|ERX|0250|AZTREONAM 1G/100ML NS|Medicaid|MEDICAID|247.75||||||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|Managed Medicaid|MEDICAID SUPERIOR|111.25||||111.25||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|Blue Cross HMO Specialty|BCBSTX HMO|111.25||||||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|Managed Medicaid|MEDICAID AMERIGROUP|||||111.25||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|Cigna|CIGNA|||||111.25||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|Medicaid|MEDICAID HMO|||||111.25||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||111.25||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|111.25||||111.25||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||111.25||| 9527771|ERX|0250|CEFTRIAXONE 250MG VIAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||111.25||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Medicare|MEDICARE ACUTE|278.50||||278.50||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|278.50||||278.50||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||278.50||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Cigna|CIGNA|||||278.50||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||278.50||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Medicaid|MEDICAID HMO|||||278.50||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|United Healthcare|UNITED HEALTHCARE|||||278.50||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||278.50||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Humana Medicare Advantage|HUMANA MA|||||278.50||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||278.50||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||278.50||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Managed Medicaid|MEDICAID SUPERIOR|278.50||||278.50||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Medicaid|MEDICAID|278.50||||278.50||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Managed Medicaid|MEDICAID AMERIGROUP|||||278.50||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|United Healthcare|UNITED HEALTHCARE|278.50||||||| 9527789|ERX|0250|CEFTRIAXONE 500MG VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||278.50||| 9527870|ERX|0250|DOXYCYCLINE 100MG/100ML N|Managed Medicaid|MEDICAID AMERIGROUP|||||103.25||| 9527870|ERX|0250|DOXYCYCLINE 100MG/100ML N|Managed Medicaid|MEDICAID SUPERIOR|103.25||||||| 9527870|ERX|0250|DOXYCYCLINE 100MG/100ML N|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|103.25||||103.25||| 9527870|ERX|0250|DOXYCYCLINE 100MG/100ML N|Medicare|MEDICARE ACUTE|103.25||||103.25||| 9527870|ERX|0250|DOXYCYCLINE 100MG/100ML N|Humana Medicare Advantage|HUMANA MA|103.25||||103.25||| 9527870|ERX|0250|DOXYCYCLINE 100MG/100ML N|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|103.25||||||| 9527870|ERX|0250|DOXYCYCLINE 100MG/100ML N|Managed Medicaid|MEDICAID UNITED HEALTHCARE|103.25||||||| 9527870|ERX|0250|DOXYCYCLINE 100MG/100ML N|United Medicare Advantage|AARP UHC WEST COMPLETE MA|103.25||||||| 9527870|ERX|0250|DOXYCYCLINE 100MG/100ML N|NON CONTRACTED|COMMERCIAL OTHER 1|103.25||||||| 9527870|ERX|0250|DOXYCYCLINE 100MG/100ML N|Blue Cross PPO Specialty|BCBSTX PPO|||||103.25||| 9527870|ERX|0250|DOXYCYCLINE 100MG/100ML N|Rusk State Hospital|RUSK STATE HOSP|103.25||||||| 9527870|ERX|0250|DOXYCYCLINE 100MG/100ML N|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|103.25||||||| 9527870|ERX|0250|DOXYCYCLINE 100MG/100ML N|Medicaid|MEDICAID|103.25||||||| 9527870|ERX|0250|DOXYCYCLINE 100MG/100ML N|Blue Cross HMO Specialty|BCBSTX HMO|103.25||||||| 9527870|ERX|0250|DOXYCYCLINE 100MG/100ML N|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|103.25||||103.25||| 9528027|ERX|0250|PANTOPRAZOLE 40MG/100ML N|Veterans Affairs|VETERANS ADMINISTRATION|||||103.25||| 9528027|ERX|0250|PANTOPRAZOLE 40MG/100ML N|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||103.25||| 9528027|ERX|0250|PANTOPRAZOLE 40MG/100ML N|Aenta Medicare Advantage|AETNA MEDICARE MA|103.25||||||| 9528027|ERX|0250|PANTOPRAZOLE 40MG/100ML N|United Medicare Advantage|AARP UHC WEST COMPLETE MA|103.25||||103.25||| 9528027|ERX|0250|PANTOPRAZOLE 40MG/100ML N|Blue Cross HMO Specialty|BCBSTX HMO|||||103.25||| 9528027|ERX|0250|PANTOPRAZOLE 40MG/100ML N|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|103.25||||||| 9528027|ERX|0250|PANTOPRAZOLE 40MG/100ML N|Aetna|AETNA PPO|103.25||||||| 9528027|ERX|0250|PANTOPRAZOLE 40MG/100ML N|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|103.25||||||| 9528027|ERX|0250|PANTOPRAZOLE 40MG/100ML N|Humana Medicare Advantage|HUMANA MA|103.25||||103.25||| 9528027|ERX|0250|PANTOPRAZOLE 40MG/100ML N|Medicare|MEDICARE ACUTE|103.25||||103.25||| 9528134|ERX|0250|VANCOMYCIN 1G/250ML NS|United Medicare Advantage|UHC MEDICARE GOLD MA|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|Cigna|CIGNA|103.25||||||| 9528134|ERX|0250|VANCOMYCIN 1G/250ML NS|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|103.25||||||| 9528134|ERX|0250|VANCOMYCIN 1G/250ML NS|Managed Medicaid|MEDICAID SUPERIOR|103.25||||||| 9528134|ERX|0250|VANCOMYCIN 1G/250ML NS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|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|Humana Medicare Advantage|HUMANA MA|103.25||||103.25||| 9528134|ERX|0250|VANCOMYCIN 1G/250ML NS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||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|Managed Medicaid|MEDICAID UNITED HEALTHCARE|103.25||||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|Aetna|AETNA PPO|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|Managed Medicaid|MEDICAID AMERIGROUP|103.25||||||| 9528134|ERX|0250|VANCOMYCIN 1G/250ML NS|Workers Compensation|WORKERS COMPENSATION OTHER|103.25||||103.25||| 9528134|ERX|0250|VANCOMYCIN 1G/250ML NS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||103.25||| 9528134|ERX|0250|VANCOMYCIN 1G/250ML NS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|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|Blue Cross PPO Specialty|BCBSTX OTHER|||||103.25||| 9528134|ERX|0250|VANCOMYCIN 1G/250ML NS|UTMB|UTMB CORRECTIONAL MANAGED CARE|103.25||||||| 9528134|ERX|0250|VANCOMYCIN 1G/250ML NS|Rusk State Hospital|RUSK STATE HOSP|103.25||||||| 9528134|ERX|0250|VANCOMYCIN 1G/250ML NS|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||103.25||| 9528134|ERX|0250|VANCOMYCIN 1G/250ML NS|Managed Medicare|HEALTHSPRING MA|103.25||||103.25||| 9528134|ERX|0250|VANCOMYCIN 1G/250ML NS|Medicare|MEDICARE ACUTE|103.25||||103.25||| 9528134|ERX|0250|VANCOMYCIN 1G/250ML NS|Medicaid|MEDICAID|103.25||||103.25||| 9528134|ERX|0250|VANCOMYCIN 1G/250ML NS|NON CONTRACTED|COMMERCIAL OTHER 1|103.25||||||| 9528142|ERX|0250|ZOSYN 2.25G/100ML NS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.29||||||| 9528142|ERX|0250|ZOSYN 2.25G/100ML NS|Rusk State Hospital|RUSK STATE HOSP|1.29||||||| 9528142|ERX|0250|ZOSYN 2.25G/100ML NS|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.29||||||| 9528142|ERX|0250|ZOSYN 2.25G/100ML NS|Medicare|MEDICARE ACUTE|1.29||||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|Managed Medicaid|MEDICAID AMERIGROUP|||||1.29||| 9528142|ERX|0250|ZOSYN 2.25G/100ML NS|Managed Medicaid|MEDICAID SUPERIOR|1.29||||1.29||| 9528142|ERX|0250|ZOSYN 2.25G/100ML NS|Humana Medicare Advantage|HUMANA MA|1.29||||||| 9528142|ERX|0250|ZOSYN 2.25G/100ML NS|Aenta Medicare Advantage|AETNA MEDICARE MA|1.29||||||| 9528142|ERX|0250|ZOSYN 2.25G/100ML NS|Blue Cross HMO Specialty|BCBSTX HMO|||||1.29||| 9528159|ERX|0250|ZOSYN 3.375G/100ML NS|Workers Compensation|WORKERS COMPENSATION OTHER|1.41||||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|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.41||||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|AARP UHC WEST COMPLETE MA|1.41||||1.41||| 9528159|ERX|0250|ZOSYN 3.375G/100ML NS|Aetna|AETNA PPO|1.41||||||| 9528159|ERX|0250|ZOSYN 3.375G/100ML NS|Aenta Medicare Advantage|AETNA MEDICARE MA|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|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|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|Managed Medicaid|MEDICAID AMERIGROUP|||||1.41||| 9528159|ERX|0250|ZOSYN 3.375G/100ML NS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|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 UNITED HEALTHCARE|1.41||||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|UNITED HEALTHCARE|1.41||||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|Blue Cross PPO Specialty|BCBSTX PPO|1.41||||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|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.41||||1.41||| 9528159|ERX|0250|ZOSYN 3.375G/100ML NS|Rusk State Hospital|RUSK STATE HOSP|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|United Medicare Advantage|UHC MEDICARE GOLD MA|1.41||||1.41||| 9528159|ERX|0250|ZOSYN 3.375G/100ML NS|Medicaid|MEDICAID|1.41||||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|Brinson Benefits|THE HEALTH PLAN SMITH CO|1.41||||||| 9528159|ERX|0250|ZOSYN 3.375G/100ML NS|Managed Medicare|HEALTHSPRING MA|1.41||||||| 9528159|ERX|0250|ZOSYN 3.375G/100ML NS|Medicaid|MOLINA HEALTHCARE OF TEXAS|1.41||||||| 9528159|ERX|0250|ZOSYN 3.375G/100ML NS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1.41||||||| 9528167|ERX|0250|ZOSYN 4.5G/100ML NS|Managed Medicaid|MEDICAID AMERIGROUP|||||1.76||| 9528167|ERX|0250|ZOSYN 4.5G/100ML NS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|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|Veterans Affairs|VETERANS ADMINISTRATION|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|Humana Medicare Advantage|HUMANA MA|1.76||||||| 9528167|ERX|0250|ZOSYN 4.5G/100ML NS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1.76||| 9528167|ERX|0250|ZOSYN 4.5G/100ML NS|Blue Cross PPO Specialty|BCBSTX PPO|||||1.76||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Blue Cross PPO Specialty|BCBSTX PPO|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 Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|103.50||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Blue Cross PPO Specialty|BCBSTX OTHER|103.50||||103.50||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|103.50||||103.50||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Aetna|AETNA PPO|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|Workers Compensation|UT EMPLOYEE INJURY|103.50||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|103.50||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Veterans Affairs|VETERANS ADMINISTRATION|103.50||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Blue Cross HMO Specialty|BCBSTX HMO|103.50||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|United Healthcare|UMR UNITED MEDICAL RESOURCES|103.50||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Workers Compensation|WORKERS COMPENSATION OTHER|103.50||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Managed Medicaid|MEDICAID SUPERIOR|103.50||||103.50||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Brinson Benefits|THE HEALTH PLAN SMITH CO|103.50||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|103.50||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|103.50||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|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 Healthcare|UNITED HEALTHCARE|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|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|103.50||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Managed Medicaid|MEDICAID AMERIGROUP|103.50||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Rusk State Hospital|RUSK STATE HOSP|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|NON CONTRACTED|COMMERCIAL OTHER 1|103.50||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|UTMB|UTMB CORRECTIONAL MANAGED CARE|103.50||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Medicare|MEDICARE ACUTE|103.50||||103.50||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Medicare|MEDICARE PART B ONLY IP|103.50||||||| 9528175|ERX|0250|INSULIN,HUMALOG 100UNIT/1|Medicaid|MEDICAID|103.50||||||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Medicare|MEDICARE PART B ONLY IP|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|||||59.50||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||59.50||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|59.50||||59.50||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Managed Medicaid|MEDICAID SUPERIOR|||||59.50||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Medicare|MEDICARE ACUTE|59.50||||59.50||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|UTMB|UTMB CORRECTIONAL MANAGED CARE|59.50||||||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Rusk State Hospital|RUSK STATE HOSP|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 Healthcare|UNITED HEALTHCARE|||||59.50||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Managed Medicare|HEALTHSPRING MA|59.50||||||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Managed Medicaid|MEDICAID AMERIGROUP|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|TML GROUP BENEFITS|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|Workers Compensation|UT EMPLOYEE INJURY|59.50||||||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|United Healthcare|UNITED HEALTHCARE OTHER|||||59.50||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|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|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||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|Brinson Benefits|THE HEALTH PLAN SMITH CO|59.50||||||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Aenta Medicare Advantage|AETNA MEDICARE MA|59.50||||59.50||| 9528183|ERX|0250|INSULIN,HUMULIN R 100UNIT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|59.50||||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|Blue Cross HMO Specialty|BCBSTX HMO|59.50||||59.50||| 9528191|ERX|0250|INSULIN,HUMULIN N 100UNIT|UTMB|UTMB CORRECTIONAL MANAGED CARE|59.50||||||| 9528191|ERX|0250|INSULIN,HUMULIN N 100UNIT|United Medicare Advantage|AARP UHC WEST COMPLETE MA|59.50||||||| 9528191|ERX|0250|INSULIN,HUMULIN N 100UNIT|Workers Compensation|WORKERS COMPENSATION OTHER|59.50||||||| 9528191|ERX|0250|INSULIN,HUMULIN N 100UNIT|Medicare|MEDICARE ACUTE|59.50||||||| 9528191|ERX|0250|INSULIN,HUMULIN N 100UNIT|Blue Cross HMO Specialty|BCBSTX HMO|||||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|Managed Medicaid|MEDICAID AMERIGROUP|59.50||||||| 9528191|ERX|0250|INSULIN,HUMULIN N 100UNIT|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|59.50||||||| 9528191|ERX|0250|INSULIN,HUMULIN N 100UNIT|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|59.50||||||| 9528191|ERX|0250|INSULIN,HUMULIN N 100UNIT|Managed Medicaid|MEDICAID SUPERIOR|||||59.50||| 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|AARP UHC WEST COMPLETE MA|0.55||||||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|Humana Medicare Advantage|HUMANA MA|0.55||||||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|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|Managed Medicaid|MEDICAID SUPERIOR|||||0.55||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|Blue Cross HMO Specialty|BCBSTX HMO|0.55||||0.55||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.55||||||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|NON CONTRACTED|COMMERCIAL OTHER 1|0.55||||||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|Medicare|MEDICARE ACUTE|0.55||||||| 9528209|ERX|0250|INSULIN,HUMULIN 70/30 100|Medicare|MEDICARE PART B ONLY IP|0.55||||||| 9528233|ERX|0250|OXYMETAZOLINE 0.05%, 30ML|Medicare|MEDICARE ACUTE|17.50||||17.50||| 9528233|ERX|0250|OXYMETAZOLINE 0.05%, 30ML|Aenta Medicare Advantage|AETNA MEDICARE MA|||||17.50||| 9528233|ERX|0250|OXYMETAZOLINE 0.05%, 30ML|Humana Medicare Advantage|HUMANA MA|||||17.50||| 9528233|ERX|0250|OXYMETAZOLINE 0.05%, 30ML|Managed Medicaid|MEDICAID SUPERIOR|||||17.50||| 9528233|ERX|0250|OXYMETAZOLINE 0.05%, 30ML|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|17.50||||||| 9528233|ERX|0250|OXYMETAZOLINE 0.05%, 30ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||17.50||| 9528233|ERX|0250|OXYMETAZOLINE 0.05%, 30ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|17.50||||||| 9528258|ERX|0250|CEPACOL LOZENGE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.11||||||| 9528258|ERX|0250|CEPACOL LOZENGE|Medicaid|MEDICAID|0.11||||||| 9528258|ERX|0250|CEPACOL LOZENGE|NON CONTRACTED|COMMERCIAL OTHER 1|0.11||||||| 9528258|ERX|0250|CEPACOL LOZENGE|Workers Compensation|UT EMPLOYEE INJURY|0.11||||||| 9528258|ERX|0250|CEPACOL LOZENGE|Veterans Affairs|VETERANS ADMINISTRATION|0.11||||||| 9528258|ERX|0250|CEPACOL LOZENGE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.11||||||| 9528258|ERX|0250|CEPACOL LOZENGE|Humana Medicare Advantage|HUMANA MA|0.11||||||| 9528258|ERX|0250|CEPACOL LOZENGE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.11||||||| 9528258|ERX|0250|CEPACOL LOZENGE|Medicare|MEDICARE ACUTE|0.11||||||| 9528258|ERX|0250|CEPACOL LOZENGE|Managed Medicare|HEALTHSPRING MA|0.11||||||| 9528324|ERX|0250|PHENYEPHRINE 0.25% NASAL|Medicare|MEDICARE ACUTE|||||32.50||| 9528365|ERX|0250|TEARS NATURALE FREE, 0.03|Managed Medicaid|MEDICAID UNITED HEALTHCARE|69.75||||||| 9528365|ERX|0250|TEARS NATURALE FREE, 0.03|United Medicare Advantage|AARP UHC WEST COMPLETE MA|69.75||||||| 9528365|ERX|0250|TEARS NATURALE FREE, 0.03|Medicare|MEDICARE ACUTE|69.75||||||| 9528365|ERX|0250|TEARS NATURALE FREE, 0.03|UTMB|UTMB CORRECTIONAL MANAGED CARE|69.75||||||| 9528365|ERX|0250|TEARS NATURALE FREE, 0.03|Humana Medicare Advantage|HUMANA MA|69.75||||||| 9528472|ERX|0250|GELATIN SPONGE, ABSORBABL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|72.50||||||| 9528472|ERX|0250|GELATIN SPONGE, ABSORBABL|United Healthcare|UNITED HEALTHCARE|||||72.50||| 9528472|ERX|0250|GELATIN SPONGE, ABSORBABL|Managed Medicaid|MEDICAID SUPERIOR|||||72.50||| 9528472|ERX|0250|GELATIN SPONGE, ABSORBABL|Tricare|TRICARE EAST REGION|||||72.50||| 9528472|ERX|0250|GELATIN SPONGE, ABSORBABL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||72.50||| 9528472|ERX|0250|GELATIN SPONGE, ABSORBABL|United Healthcare|UNITED HEALTHCARE OTHER|||||72.50||| 9528472|ERX|0250|GELATIN SPONGE, ABSORBABL|Medicare|MEDICARE ACUTE|72.50||||72.50||| 9528472|ERX|0250|GELATIN SPONGE, ABSORBABL|Veterans Affairs|VETERANS ADMINISTRATION|72.50||||||| 9528472|ERX|0250|GELATIN SPONGE, ABSORBABL|United Medicare Advantage|UHC MEDICARE GOLD MA|72.50||||72.50||| 9528472|ERX|0250|GELATIN SPONGE, ABSORBABL|NON CONTRACTED|COMMERCIAL OTHER 1|||||72.50||| 9528472|ERX|0250|GELATIN SPONGE, ABSORBABL|Aenta Medicare Advantage|AETNA MEDICARE MA|72.50||||72.50||| 9528472|ERX|0250|GELATIN SPONGE, ABSORBABL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||72.50||| 9528472|ERX|0250|GELATIN SPONGE, ABSORBABL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||72.50||| 9528472|ERX|0250|GELATIN SPONGE, ABSORBABL|Blue Cross PPO Specialty|BCBSTX OTHER|||||72.50||| 9528472|ERX|0250|GELATIN SPONGE, ABSORBABL|Blue Cross PPO Specialty|BCBSTX PPO|||||72.50||| 9528472|ERX|0250|GELATIN SPONGE, ABSORBABL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|72.50||||72.50||| 9528472|ERX|0250|GELATIN SPONGE, ABSORBABL|Humana Medicare Advantage|HUMANA MA|72.50||||72.50||| 9528472|ERX|0250|GELATIN SPONGE, ABSORBABL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||72.50||| 9528472|ERX|0250|GELATIN SPONGE, ABSORBABL|Blue Cross HMO Specialty|BCBSTX HMO|||||72.50||| 9528522|ERX|0250|CARVEDILOL CR 10MG CAPSUL|Blue Cross PPO Specialty|BCBSTX OTHER|||||42.50||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||103.25||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Medicaid|MEDICAID|103.25||||||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||103.25||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|103.25||||103.25||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Managed Medicare|HEALTHSPRING MA|103.25||||||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Managed Medicaid|MEDICAID SUPERIOR|103.25||||||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|UTMB|UTMB CORRECTIONAL MANAGED CARE|103.25||||||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|NON CONTRACTED|COMMERCIAL OTHER 1|103.25||||103.25||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Managed Medicaid|MEDICAID AMERIGROUP|103.25||||||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|United Healthcare|UNITED HEALTHCARE OTHER|103.25||||||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Humana Medicare Advantage|HUMANA MA|103.25||||103.25||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Workers Compensation|UT EMPLOYEE INJURY|103.25||||||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Cigna|CIGNA|||||103.25||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Blue Cross HMO Specialty|BCBSTX HMO|||||103.25||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||103.25||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Blue Cross PPO Specialty|BCBSTX PPO|103.25||||103.25||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Medicare|MEDICARE ACUTE|103.25||||103.25||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|103.25||||||| 9528555|ERX|0250|POTASSIUM CHLORIDE 10MEQ/|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|103.25||||103.25||| 9528746|ERX|0250|POTASSIUM CHLORIDE 40MEQ/|Aenta Medicare Advantage|AETNA MEDICARE MA|103.25||||||| 9528746|ERX|0250|POTASSIUM CHLORIDE 40MEQ/|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||103.25||| 9528746|ERX|0250|POTASSIUM CHLORIDE 40MEQ/|Blue Cross HMO Specialty|BCBSTX HMO|103.25||||103.25||| 9528746|ERX|0250|POTASSIUM CHLORIDE 40MEQ/|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|103.25||||||| 9528746|ERX|0250|POTASSIUM CHLORIDE 40MEQ/|Humana Medicare Advantage|HUMANA MA|103.25||||||| 9528746|ERX|0250|POTASSIUM CHLORIDE 40MEQ/|Blue Cross PPO Specialty|BCBSTX PPO|103.25||||||| 9528746|ERX|0250|POTASSIUM CHLORIDE 40MEQ/|Cigna|CIGNA|||||103.25||| 9528746|ERX|0250|POTASSIUM CHLORIDE 40MEQ/|United Healthcare|UNITED HEALTHCARE|103.25||||||| 9528746|ERX|0250|POTASSIUM CHLORIDE 40MEQ/|Veterans Affairs|VETERANS ADMINISTRATION|103.25||||||| 9528746|ERX|0250|POTASSIUM CHLORIDE 40MEQ/|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|103.25||||||| 9528746|ERX|0250|POTASSIUM CHLORIDE 40MEQ/|Rusk State Hospital|RUSK STATE HOSP|103.25||||||| 9528746|ERX|0250|POTASSIUM CHLORIDE 40MEQ/|Cigna|CIGNA|103.25||||||| 9528746|ERX|0250|POTASSIUM CHLORIDE 40MEQ/|United Medicare Advantage|AARP UHC WEST COMPLETE MA|103.25||||||| 9528746|ERX|0250|POTASSIUM CHLORIDE 40MEQ/|Medicare|MEDICARE ACUTE|103.25||||||| 9528746|ERX|0250|POTASSIUM CHLORIDE 40MEQ/|UTMB|UTMB CORRECTIONAL MANAGED CARE|103.25||||||| 9528746|ERX|0250|POTASSIUM CHLORIDE 40MEQ/|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|103.25||||||| 9528746|ERX|0250|POTASSIUM CHLORIDE 40MEQ/|Managed Medicare|HEALTHSPRING MA|103.25||||||| 9528746|ERX|0250|POTASSIUM CHLORIDE 40MEQ/|Medicaid|MEDICAID|103.25||||||| 9528746|ERX|0250|POTASSIUM CHLORIDE 40MEQ/|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||103.25||| 9528746|ERX|0250|POTASSIUM CHLORIDE 40MEQ/|Workers Compensation|WORKERS COMPENSATION OTHER|103.25||||||| 9528746|ERX|0250|POTASSIUM CHLORIDE 40MEQ/|Workers Compensation|UT EMPLOYEE INJURY|103.25||||||| 9528746|ERX|0250|POTASSIUM CHLORIDE 40MEQ/|United Medicare Advantage|UHC MEDICARE GOLD MA|103.25||||||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Managed Medicaid|MEDICAID SUPERIOR|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Managed Medicare|HEALTHSPRING MA|0.16||||||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Managed Medicare|HOSPICE OF EAST TEXAS|0.16||||||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||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||||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|Tricare|TRICARE EAST REGION|||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|United Healthcare|TML GROUP BENEFITS|||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Medicare|MEDICARE ACUTE|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Rusk State Hospital|RUSK STATE HOSP|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|United Healthcare|UMR UNITED MEDICAL RESOURCES|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|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Medicare|MEDICARE PART B ONLY IP|0.16||||||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|United Healthcare|UNITED HEALTHCARE OTHER|||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Medicaid|MEDICAID|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Veterans Affairs|VETERANS ADMINISTRATION|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|United Healthcare|UNITED HEALTHCARE|||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||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 DUAL COMPLETE HMO SNP MA|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|Medicaid|SUPERIOR HEALTHPLAN CHIP|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Cigna|CIGNA|0.16||||||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Blue Cross HMO Specialty|BCBSTX HMO|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Blue Cross PPO Specialty|BCBSTX PPO|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Aetna|AETNA PPO|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Workers Compensation|WORKERS COMPENSATION OTHER|0.16||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Aetna|AETNA OTHER|||||0.16||| 9528860|ERX|0250|MORPHINE 4MG/ML VIAL|Humana Medicare Advantage|HUMANA MA|0.16||||0.16||| 9529033|ERX|0250|CALCIUM GLUCONATE 10% VIA|Medicare|MEDICARE ACUTE|39.25||||||| 9529074|ERX|0250|TELMISARTAN 40MG TABLET|Managed Medicare|HEALTHSPRING MA|18.25||||||| 9529074|ERX|0250|TELMISARTAN 40MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||18.25||| 9529074|ERX|0250|TELMISARTAN 40MG TABLET|Humana Medicare Advantage|HUMANA MA|18.25||||||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Medicare|MEDICARE ACUTE|||||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||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Humana Medicare Advantage|HUMANA MA|490.20||||||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||490.20||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Aetna|AETNA PPO|490.20||||||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Blue Cross PPO Specialty|BCBSTX PPO|||||490.20||| 9529140|ERX|0250|SUGAMMADEX 200MG/2ML VIAL|Blue Cross HMO Specialty|BCBSTX HMO|||||490.20||| 9529157|ERX|0250|LINACLOTIDE 145MCG CAPSUL|Medicare|MEDICARE ACUTE|74.88||||||| 9529504|ERX|0250|CEFDINIR 250 MG/5 ML SUSP|Managed Medicaid|MEDICAID SUPERIOR|496.75||||||| 9529504|ERX|0250|CEFDINIR 250 MG/5 ML SUSP|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|496.75||||||| 9529587|ERX|0250|MULTIVITAMIN LIQUID 30 ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|8.80||||||| 9529587|ERX|0250|MULTIVITAMIN LIQUID 30 ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8.80||||||| 9529587|ERX|0250|MULTIVITAMIN LIQUID 30 ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|8.80||||||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Medicaid|MEDICAID|||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Medicare|MEDICARE PART B ONLY IP|||||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||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Managed Medicare|BCBS MEDICARE PPO MA|||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||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%|Aenta Medicare Advantage|AETNA MEDICARE MA|877.20||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Aetna|AETNA OTHER|||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Aetna|AETNA PPO|||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Managed Medicaid|MEDICAID SUPERIOR|||||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%|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|United Healthcare|UNITED HEALTHCARE OTHER|||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Workers Compensation|WORKERS COMPENSATION OTHER|||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Cigna|CIGNA|||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|United Healthcare|UNITED HEALTHCARE|||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|United Medicare Advantage|UHC MEDICARE GOLD MA|877.20||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Blue Cross PPO Specialty|BCBSTX PPO|||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|United Medicare Advantage|AARP UHC WEST COMPLETE MA|877.20||||||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Humana Medicare Advantage|HUMANA MA|877.20||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Blue Cross HMO Specialty|BCBSTX HMO|||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||877.20||| 9529660|ERX|0250|BUPIVACAINE LIPOSOME 1.3%|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||877.20||| 95810|EAP|0920|SLEEP STUDY 4+PARAMETERS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||4,715.25||| 95810|EAP|0920|SLEEP STUDY 4+PARAMETERS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||4,715.25||| 95810|EAP|0920|SLEEP STUDY 4+PARAMETERS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||4,715.25||| 95810|EAP|0920|SLEEP STUDY 4+PARAMETERS|Veterans Affairs|VETERANS ADMINISTRATION|||||4,715.25||| 95810|EAP|0920|SLEEP STUDY 4+PARAMETERS|Medicare|MEDICARE ACUTE|||||4,715.25||| 95810|EAP|0920|SLEEP STUDY 4+PARAMETERS|Aenta Medicare Advantage|AETNA MEDICARE MA|||||4,715.25||| 95810|EAP|0920|SLEEP STUDY 4+PARAMETERS|Aetna|AETNA PPO|||||4,715.25||| 95810|EAP|0920|SLEEP STUDY 4+PARAMETERS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||4,715.25||| 95810|EAP|0920|SLEEP STUDY 4+PARAMETERS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||4,715.25||| 95810|EAP|0920|SLEEP STUDY 4+PARAMETERS|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||4,715.25||| 95810|EAP|0920|SLEEP STUDY 4+PARAMETERS|United Medicare Advantage|UHC MEDICARE GOLD MA|||||4,715.25||| 95810|EAP|0920|SLEEP STUDY 4+PARAMETERS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||4,715.25||| 95810|EAP|0920|SLEEP STUDY 4+PARAMETERS|Managed Medicaid|MEDICAID SUPERIOR|||||4,715.25||| 95810|EAP|0920|SLEEP STUDY 4+PARAMETERS|Managed Medicaid|MEDICAID AMERIGROUP|||||4,715.25||| 95810|EAP|0920|SLEEP STUDY 4+PARAMETERS|Blue Cross HMO Specialty|BCBSTX HMO|||||4,715.25||| 95810|EAP|0920|SLEEP STUDY 4+PARAMETERS|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||4,715.25||| 95810|EAP|0920|SLEEP STUDY 4+PARAMETERS|NON CONTRACTED|COMMERCIAL OTHER 1|||||4,715.25||| 95810|EAP|0920|SLEEP STUDY 4+PARAMETERS|Blue Cross PPO Specialty|BCBSTX PPO|||||4,715.25||| 95810|EAP|0920|SLEEP STUDY 4+PARAMETERS|Humana Medicare Advantage|HUMANA MA|||||4,715.25||| 95810|EAP|0920|SLEEP STUDY 4+PARAMETERS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||4,715.25||| 95810|EAP|0920|SLEEP STUDY 4+PARAMETERS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||4,715.25||| 95811|EAP|0920|SLEEP STUDY 4+PARA/POS AI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||5,205.25||| 95811|EAP|0920|SLEEP STUDY 4+PARA/POS AI|Medicare|MEDICARE ACUTE|||||5,205.25||| 95811|EAP|0920|SLEEP STUDY 4+PARA/POS AI|PHCS|HUMANA INSURANCE|||||5,205.25||| 95811|EAP|0920|SLEEP STUDY 4+PARA/POS AI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||5,205.25||| 95811|EAP|0920|SLEEP STUDY 4+PARA/POS AI|NON CONTRACTED|COMMERCIAL OTHER 1|||||5,205.25||| 95811|EAP|0920|SLEEP STUDY 4+PARA/POS AI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||5,205.25||| 95811|EAP|0920|SLEEP STUDY 4+PARA/POS AI|Managed Medicaid|MEDICAID SUPERIOR|||||5,205.25||| 95811|EAP|0920|SLEEP STUDY 4+PARA/POS AI|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||5,205.25||| 95811|EAP|0920|SLEEP STUDY 4+PARA/POS AI|Blue Cross PPO Specialty|BCBSTX PPO|||||5,205.25||| 95811|EAP|0920|SLEEP STUDY 4+PARA/POS AI|Humana Medicare Advantage|HUMANA MA|||||5,205.25||| 95811|EAP|0920|SLEEP STUDY 4+PARA/POS AI|Blue Cross PPO Specialty|BCBSTX OTHER|||||5,205.25||| 95811|EAP|0920|SLEEP STUDY 4+PARA/POS AI|Cigna|CIGNA|||||5,205.25||| 95811|EAP|0920|SLEEP STUDY 4+PARA/POS AI|United Medicare Advantage|UHC MEDICARE GOLD MA|||||5,205.25||| 95811|EAP|0920|SLEEP STUDY 4+PARA/POS AI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||5,205.25||| 95811|EAP|0920|SLEEP STUDY 4+PARA/POS AI|Aetna|AETNA PPO|||||5,205.25||| 95811|EAP|0920|SLEEP STUDY 4+PARA/POS AI|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||5,205.25||| 95811|EAP|0920|SLEEP STUDY 4+PARA/POS AI|Blue Cross HMO Specialty|BCBSTX HMO|||||5,205.25||| 95812|EAP|0740|EEG EXTENDED MONITORING 4|NON CONTRACTED|COMMERCIAL OTHER 1|||||21.00||| 95812|EAP|0740|EEG EXTENDED MONITORING 4|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||21.00||| 95812|EAP|0740|EEG EXTENDED MONITORING 4|Blue Cross HMO Specialty|BCBSTX HMO|||||21.00||| 95812|EAP|0740|EEG EXTENDED MONITORING 4|Blue Cross PPO Specialty|BCBSTX PPO|||||21.00||| 95812|EAP|0740|EEG EXTENDED MONITORING 4|Managed Medicaid|MEDICAID SUPERIOR|||||21.00||| 95812|EAP|0740|EEG EXTENDED MONITORING 4|Managed Medicaid|MEDICAID AMERIGROUP|||||21.00||| 95816|EAP|0740|EEG AWAKE AND DROWSY|Humana Medicare Advantage|HUMANA MA|||||17.50||| 95816|EAP|0740|EEG AWAKE AND DROWSY|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|17.50||||||| 95816|EAP|0740|EEG AWAKE AND DROWSY|Managed Medicaid|MEDICAID SUPERIOR|||||17.50||| 95816|EAP|0740|EEG AWAKE AND DROWSY|Medicare|MEDICARE ACUTE|17.50||||||| 95816|EAP|0740|EEG AWAKE AND DROWSY|Aenta Medicare Advantage|AETNA MEDICARE MA|17.50||||||| 95816|EAP|0740|EEG AWAKE AND DROWSY|Medicaid|MEDICAID|17.50||||||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|Blue Cross PPO Specialty|BCBSTX PPO|19.42||||||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|19.42||||||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|Blue Cross HMO Specialty|BCBSTX HMO|19.42||||||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|Managed Medicaid|MEDICAID SUPERIOR|||||19.42||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|Medicare|MEDICARE ACUTE|19.42||||||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|UTMB|UTMB CORRECTIONAL MANAGED CARE|19.42||||||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||19.42||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|NON CONTRACTED|COMMERCIAL OTHER 1|||||19.42||| 95819|EAP|0740|EEG AWAKE AND ASLEEP|Humana Medicare Advantage|HUMANA MA|19.42||||||| 9582909|ERX|0250|ACERAM-CODEINE 300 30MG 1|United Healthcare|UNITED HEALTHCARE|||||10.75||| 9582933|ERX|0250|AMIODARONE 360MG 200ML DE|Medicare|MEDICARE ACUTE|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|Managed Medicare|HEALTHSPRING MA|293.75||||||| 9582933|ERX|0250|AMIODARONE 360MG 200ML DE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|293.75||||||| 9582933|ERX|0250|AMIODARONE 360MG 200ML DE|Humana Medicare Advantage|HUMANA MA|293.75||||||| 9582958|ERX|0250|BENAZEPRIL 10MG TABLET|United Healthcare|UMR UNITED MEDICAL RESOURCES|0.10||||||| 9582958|ERX|0250|BENAZEPRIL 10MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.10||||||| 9582958|ERX|0250|BENAZEPRIL 10MG TABLET|Cigna|CIGNA|0.10||||||| 9582958|ERX|0250|BENAZEPRIL 10MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.10||||||| 9582958|ERX|0250|BENAZEPRIL 10MG TABLET|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.10||| 9582958|ERX|0250|BENAZEPRIL 10MG TABLET|Humana Medicare Advantage|HUMANA MA|0.10||||0.10||| 9582958|ERX|0250|BENAZEPRIL 10MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.10||||||| 9582958|ERX|0250|BENAZEPRIL 10MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.10||| 9582958|ERX|0250|BENAZEPRIL 10MG TABLET|Medicare|MEDICARE ACUTE|0.10||||0.10||| 9582958|ERX|0250|BENAZEPRIL 10MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.10||||||| 9582982|ERX|0250|HYDROMORPHONE 1MG/ML AMPU|Medicare|MEDICARE ACUTE|0.13||||0.13||| 9582982|ERX|0250|HYDROMORPHONE 1MG/ML AMPU|Rusk State Hospital|RUSK STATE HOSP|||||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||||0.13||| 9582982|ERX|0250|HYDROMORPHONE 1MG/ML AMPU|Managed Medicare|HOSPICE OF EAST TEXAS|0.13||||||| 9582982|ERX|0250|HYDROMORPHONE 1MG/ML AMPU|Medicaid|MEDICAID|0.13||||0.13||| 9582982|ERX|0250|HYDROMORPHONE 1MG/ML AMPU|Brinson Benefits|THE HEALTH PLAN SMITH CO|0.13||||||| 9582982|ERX|0250|HYDROMORPHONE 1MG/ML AMPU|Cigna|CIGNA|||||0.13||| 9582982|ERX|0250|HYDROMORPHONE 1MG/ML AMPU|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||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|Aenta Medicare Advantage|AETNA MEDICARE MA|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|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||0.13||| 9582982|ERX|0250|HYDROMORPHONE 1MG/ML AMPU|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.13||| 9582982|ERX|0250|HYDROMORPHONE 1MG/ML AMPU|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.13||| 9582982|ERX|0250|HYDROMORPHONE 1MG/ML AMPU|United Healthcare|UNITED HEALTHCARE|||||0.13||| 9582982|ERX|0250|HYDROMORPHONE 1MG/ML AMPU|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||0.13||| 9582982|ERX|0250|HYDROMORPHONE 1MG/ML AMPU|United Healthcare|UNITED HEALTHCARE OTHER|||||0.13||| 9582982|ERX|0250|HYDROMORPHONE 1MG/ML AMPU|Blue Cross HMO Specialty|BCBSTX HMO|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|Workers Compensation|WORKERS COMPENSATION OTHER|0.13||||0.13||| 9582982|ERX|0250|HYDROMORPHONE 1MG/ML AMPU|Veterans Affairs|VETERANS ADMINISTRATION|||||0.13||| 9582982|ERX|0250|HYDROMORPHONE 1MG/ML AMPU|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.13||||||| 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|Aetna|AETNA PPO|||||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|Humana Medicare Advantage|HUMANA MA|0.13||||0.13||| 9582982|ERX|0250|HYDROMORPHONE 1MG/ML AMPU|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.13||| 9582982|ERX|0250|HYDROMORPHONE 1MG/ML AMPU|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.13||||||| 9582982|ERX|0250|HYDROMORPHONE 1MG/ML AMPU|Managed Medicaid|MEDICAID SUPERIOR|0.13||||0.13||| 9582990|ERX|0250|LIDOCAINE 1% MDV 10ML VIA|United Healthcare|UNITED HEALTHCARE OTHER|||||12.25||| 9582990|ERX|0250|LIDOCAINE 1% MDV 10ML VIA|United Healthcare|UNITED HEALTHCARE|12.25||||12.25||| 9582990|ERX|0250|LIDOCAINE 1% MDV 10ML VIA|Workers Compensation|WORKERS COMPENSATION OTHER|12.25||||12.25||| 9582990|ERX|0250|LIDOCAINE 1% MDV 10ML VIA|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|12.25||||||| 9582990|ERX|0250|LIDOCAINE 1% MDV 10ML VIA|United Medicare Advantage|AARP UHC WEST COMPLETE MA|12.25||||12.25||| 9582990|ERX|0250|LIDOCAINE 1% MDV 10ML VIA|Humana Medicare Advantage|HUMANA MA|12.25||||12.25||| 9582990|ERX|0250|LIDOCAINE 1% MDV 10ML VIA|Blue Cross HMO Specialty|BCBSTX HMO|12.25||||12.25||| 9582990|ERX|0250|LIDOCAINE 1% MDV 10ML VIA|Aetna|AETNA PPO|12.25||||12.25||| 9582990|ERX|0250|LIDOCAINE 1% MDV 10ML VIA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||12.25||| 9582990|ERX|0250|LIDOCAINE 1% MDV 10ML VIA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|12.25||||12.25||| 9582990|ERX|0250|LIDOCAINE 1% MDV 10ML VIA|Blue Cross PPO Specialty|BCBSTX OTHER|||||12.25||| 9582990|ERX|0250|LIDOCAINE 1% MDV 10ML VIA|Cigna|CIGNA|||||12.25||| 9582990|ERX|0250|LIDOCAINE 1% MDV 10ML VIA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|12.25||||12.25||| 9582990|ERX|0250|LIDOCAINE 1% MDV 10ML VIA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|12.25||||12.25||| 9582990|ERX|0250|LIDOCAINE 1% MDV 10ML VIA|Blue Cross PPO Specialty|BCBSTX PPO|12.25||||12.25||| 9582990|ERX|0250|LIDOCAINE 1% MDV 10ML VIA|Aetna|AETNA OTHER|||||12.25||| 9582990|ERX|0250|LIDOCAINE 1% MDV 10ML VIA|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||12.25||| 9582990|ERX|0250|LIDOCAINE 1% MDV 10ML VIA|Managed Medicaid|MEDICAID SUPERIOR|12.25||||12.25||| 9582990|ERX|0250|LIDOCAINE 1% MDV 10ML VIA|Managed Medicare|HEALTHSPRING MA|||||12.25||| 9582990|ERX|0250|LIDOCAINE 1% MDV 10ML VIA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|12.25||||12.25||| 9582990|ERX|0250|LIDOCAINE 1% MDV 10ML VIA|United Medicare Advantage|UHC MEDICARE GOLD MA|12.25||||12.25||| 9582990|ERX|0250|LIDOCAINE 1% MDV 10ML VIA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12.25||||12.25||| 9582990|ERX|0250|LIDOCAINE 1% MDV 10ML VIA|Managed Medicaid|MEDICAID AMERIGROUP|||||12.25||| 9582990|ERX|0250|LIDOCAINE 1% MDV 10ML VIA|Aenta Medicare Advantage|AETNA MEDICARE MA|12.25||||12.25||| 9582990|ERX|0250|LIDOCAINE 1% MDV 10ML VIA|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||12.25||| 9582990|ERX|0250|LIDOCAINE 1% MDV 10ML VIA|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||12.25||| 9582990|ERX|0250|LIDOCAINE 1% MDV 10ML VIA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|12.25||||12.25||| 9582990|ERX|0250|LIDOCAINE 1% MDV 10ML VIA|Medicaid|MEDICAID|12.25||||12.25||| 9582990|ERX|0250|LIDOCAINE 1% MDV 10ML VIA|NON CONTRACTED|COMMERCIAL OTHER 1|12.25||||12.25||| 9582990|ERX|0250|LIDOCAINE 1% MDV 10ML VIA|Medicare|MEDICARE ACUTE|12.25||||12.25||| 9582990|ERX|0250|LIDOCAINE 1% MDV 10ML VIA|Medicare|MEDICARE PART B ONLY IP|||||12.25||| 9582990|ERX|0250|LIDOCAINE 1% MDV 10ML VIA|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|12.25||||12.25||| 9582990|ERX|0250|LIDOCAINE 1% MDV 10ML VIA|Tricare|TRICARE EAST REGION|||||12.25||| 9582990|ERX|0250|LIDOCAINE 1% MDV 10ML VIA|UTMB|UTMB CORRECTIONAL MANAGED CARE|12.25||||||| 9582990|ERX|0250|LIDOCAINE 1% MDV 10ML VIA|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||12.25||| 9583014|ERX|0250|WARFARIN 3MG TABLET|Managed Medicare|HEALTHSPRING MA|12.25||||||| 9583014|ERX|0250|WARFARIN 3MG TABLET|Medicare|MEDICARE ACUTE|12.25||||||| 9583014|ERX|0250|WARFARIN 3MG TABLET|Humana Medicare Advantage|HUMANA MA|12.25||||||| 9583014|ERX|0250|WARFARIN 3MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|12.25||||||| 9583063|ERX|0250|OLMESARTAN 20MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||29.50||| 9583063|ERX|0250|OLMESARTAN 20MG TABLET|Medicare|MEDICARE ACUTE|29.50||||||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Medicare|MEDICARE ACUTE|0.10||||||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Medicaid|MEDICAID|0.10||||||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|NON CONTRACTED|COMMERCIAL OTHER 1|0.10||||||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.10||||||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Humana Medicare Advantage|HUMANA MA|0.10||||||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Rusk State Hospital|RUSK STATE HOSP|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|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.10||||||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|United Medicare Advantage|UHC MEDICARE GOLD MA|0.10||||||| 9583071|ERX|0250|GUAIFENESIN-DM 100-10MG/5|Blue Cross HMO Specialty|BCBSTX HMO|0.10||||||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|95.75||||95.75||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Blue Cross HMO Specialty|BCBSTX HMO|95.75||||95.75||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Aenta Medicare Advantage|AETNA MEDICARE MA|95.75||||||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Aetna|AETNA OTHER|||||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|Blue Cross PPO Specialty|BCBSTX PPO|95.75||||95.75||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Aetna|AETNA PPO|||||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|Humana Medicare Advantage|HUMANA MA|95.75||||95.75||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||95.75||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|United Healthcare|UNITED HEALTHCARE|95.75||||95.75||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|United Healthcare|UNITED HEALTHCARE OTHER|95.75||||95.75||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Workers Compensation|WORKERS COMPENSATION OTHER|95.75||||95.75||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|United Medicare Advantage|AARP UHC WEST COMPLETE MA|95.75||||||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Cigna|CIGNA|95.75||||||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||95.75||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Medicaid|MEDICAID|95.75||||95.75||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Managed Medicaid|MEDICAID UNITED HEALTHCARE|95.75||||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 CIGNA HEALTHSPRING|95.75||||95.75||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Tricare|TRICARE EAST REGION|95.75||||||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||95.75||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Managed Medicaid|MEDICAID SUPERIOR|95.75||||95.75||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||95.75||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Medicare|MEDICARE PART B ONLY IP|||||95.75||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Medicare|MEDICARE ACUTE|95.75||||95.75||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|NON CONTRACTED|COMMERCIAL OTHER 1|95.75||||95.75||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|95.75||||95.75||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|Blue Cross PPO Specialty|BCBSTX OTHER|||||95.75||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|United Healthcare|UNITED HEALTHCARE|||||95.75||| 9583097|ERX|0250|CEFAZOLIN 2GM 50ML D5W|United Medicare Advantage|UHC MEDICARE GOLD MA|95.75||||||| 9583253|ERX|0250|DOPAMINE 400MG/250ML D5W|Managed Medicare|HEALTHSPRING MA|95.75||||||| 9583253|ERX|0250|DOPAMINE 400MG/250ML D5W|United Healthcare|UNITED HEALTHCARE|95.75||||||| 9583253|ERX|0250|DOPAMINE 400MG/250ML D5W|Humana Medicare Advantage|HUMANA 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|Blue Cross HMO Specialty|BCBSTX HMO|95.75||||||| 9583253|ERX|0250|DOPAMINE 400MG/250ML D5W|Medicaid|MEDICAID|95.75||||95.75||| 9583253|ERX|0250|DOPAMINE 400MG/250ML D5W|Medicare|MEDICARE ACUTE|95.75||||95.75||| 9583253|ERX|0250|DOPAMINE 400MG/250ML D5W|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|95.75||||||| 9583253|ERX|0250|DOPAMINE 400MG/250ML D5W|Managed Medicaid|MEDICAID UNITED HEALTHCARE|95.75||||||| 9583253|ERX|0250|DOPAMINE 400MG/250ML D5W|Managed Medicaid|MEDICAID SUPERIOR|95.75||||||| 9583279|ERX|0250|DILTIAZEM 125MG/25ML VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.45||||||| 9583279|ERX|0250|DILTIAZEM 125MG/25ML VIAL|Humana Medicare Advantage|HUMANA MA|0.45||||0.45||| 9583279|ERX|0250|DILTIAZEM 125MG/25ML VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.45||||||| 9583279|ERX|0250|DILTIAZEM 125MG/25ML VIAL|Managed Medicare|HEALTHSPRING MA|0.45||||||| 9583279|ERX|0250|DILTIAZEM 125MG/25ML VIAL|Medicare|MEDICARE ACUTE|0.45||||0.45||| 9583279|ERX|0250|DILTIAZEM 125MG/25ML VIAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||0.45||| 9583279|ERX|0250|DILTIAZEM 125MG/25ML VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|0.45||||0.45||| 9583279|ERX|0250|DILTIAZEM 125MG/25ML VIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.45||| 9583279|ERX|0250|DILTIAZEM 125MG/25ML VIAL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||0.45||| 9583311|ERX|0250|TRANDOLAPRIL 1MG TABLET|Medicare|MEDICARE ACUTE|0.10||||||| 9583329|ERX|0250|FLEET ENEMA (ADULT) 4.5OZ|Managed Medicaid|MEDICAID SUPERIOR|||||13.50||| 9583329|ERX|0250|FLEET ENEMA (ADULT) 4.5OZ|Medicare|MEDICARE ACUTE|13.50||||13.50||| 9583329|ERX|0250|FLEET ENEMA (ADULT) 4.5OZ|NON CONTRACTED|COMMERCIAL OTHER 1|13.50||||||| 9583329|ERX|0250|FLEET ENEMA (ADULT) 4.5OZ|Blue Cross PPO Specialty|BCBSTX OTHER|13.50||||||| 9583329|ERX|0250|FLEET ENEMA (ADULT) 4.5OZ|Workers Compensation|WORKERS COMPENSATION OTHER|13.50||||||| 9583329|ERX|0250|FLEET ENEMA (ADULT) 4.5OZ|Humana Medicare Advantage|HUMANA MA|13.50||||13.50||| 9583329|ERX|0250|FLEET ENEMA (ADULT) 4.5OZ|United Medicare Advantage|UHC MEDICARE GOLD MA|||||13.50||| 9583428|ERX|0250|LISINOPRIL 40MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.10||||||| 9583428|ERX|0250|LISINOPRIL 40MG TABLET|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.10||| 9583428|ERX|0250|LISINOPRIL 40MG TABLET|Medicaid|MEDICAID|||||0.10||| 9583428|ERX|0250|LISINOPRIL 40MG TABLET|Medicare|MEDICARE ACUTE|0.10||||||| 9583428|ERX|0250|LISINOPRIL 40MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.10||||||| 9583428|ERX|0250|LISINOPRIL 40MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.10||||||| 9583428|ERX|0250|LISINOPRIL 40MG TABLET|Humana Medicare Advantage|HUMANA MA|0.10||||0.10||| 9583428|ERX|0250|LISINOPRIL 40MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.10||||||| 9583428|ERX|0250|LISINOPRIL 40MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|0.10||||||| 9583428|ERX|0250|LISINOPRIL 40MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.10||||||| 9583683|ERX|0250|MINERAL OIL ENEMA 133ML|Workers Compensation|WORKERS COMPENSATION OTHER|0.19||||||| 9583733|ERX|0250|OSELTAMIVIR 6MG/ML SUSP 6|Managed Medicaid|MEDICAID AMERIGROUP|||||585.25||| 9583733|ERX|0250|OSELTAMIVIR 6MG/ML SUSP 6|Medicaid|MEDICAID TEXAS CHILDRENS|||||585.25||| 9583733|ERX|0250|OSELTAMIVIR 6MG/ML SUSP 6|Medicaid|MEDICAID|||||585.25||| 9583733|ERX|0250|OSELTAMIVIR 6MG/ML SUSP 6|Managed Medicaid|MEDICAID SUPERIOR|585.25||||585.25||| 9583733|ERX|0250|OSELTAMIVIR 6MG/ML SUSP 6|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||585.25||| 9583733|ERX|0250|OSELTAMIVIR 6MG/ML SUSP 6|Medicare|MEDICARE ACUTE|||||585.25||| 9583733|ERX|0250|OSELTAMIVIR 6MG/ML SUSP 6|Cigna|CIGNA|||||585.25||| 9583733|ERX|0250|OSELTAMIVIR 6MG/ML SUSP 6|Blue Cross HMO Specialty|BCBSTX HMO|||||585.25||| 9583733|ERX|0250|OSELTAMIVIR 6MG/ML SUSP 6|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||585.25||| 9583733|ERX|0250|OSELTAMIVIR 6MG/ML SUSP 6|Blue Cross PPO Specialty|BCBSTX PPO|585.25||||585.25||| 9583733|ERX|0250|OSELTAMIVIR 6MG/ML SUSP 6|Humana Medicare Advantage|HUMANA MA|||||585.25||| 9583733|ERX|0250|OSELTAMIVIR 6MG/ML SUSP 6|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||585.25||| 9583766|ERX|0250|LEVALBUTEROL 1.25MG/.05ML|Humana Medicare Advantage|HUMANA MA|48.50||||48.50||| 9583766|ERX|0250|LEVALBUTEROL 1.25MG/.05ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|48.50||||||| 9583766|ERX|0250|LEVALBUTEROL 1.25MG/.05ML|Managed Medicaid|MEDICAID SUPERIOR|48.50||||||| 9583766|ERX|0250|LEVALBUTEROL 1.25MG/.05ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|48.50||||48.50||| 9583766|ERX|0250|LEVALBUTEROL 1.25MG/.05ML|Medicare|MEDICARE ACUTE|48.50||||||| 9583766|ERX|0250|LEVALBUTEROL 1.25MG/.05ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|48.50||||||| 9583766|ERX|0250|LEVALBUTEROL 1.25MG/.05ML|Managed Medicare|HEALTHSPRING MA|48.50||||||| 9583808|ERX|0250|RISPERIDONE 0.5MG TABLET|Medicare|MEDICARE ACUTE|46.75||||||| 9583816|ERX|0250|PROCALAMINE 1000ML BOTTLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|721.25||||||| 9583816|ERX|0250|PROCALAMINE 1000ML BOTTLE|Humana Medicare Advantage|HUMANA MA|721.25||||||| 9583816|ERX|0250|PROCALAMINE 1000ML BOTTLE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|721.25||||||| 9583816|ERX|0250|PROCALAMINE 1000ML BOTTLE|Veterans Affairs|VETERANS ADMINISTRATION|721.25||||||| 9583816|ERX|0250|PROCALAMINE 1000ML BOTTLE|Managed Medicare|HEALTHSPRING MA|721.25||||||| 9583816|ERX|0250|PROCALAMINE 1000ML BOTTLE|Rusk State Hospital|RUSK STATE HOSP|721.25||||||| 9583816|ERX|0250|PROCALAMINE 1000ML BOTTLE|Medicare|MEDICARE ACUTE|721.25||||||| 9583857|ERX|0250|POTASSIUM CHLORIDE O/S 20|Managed Medicare|HEALTHSPRING MA|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|Medicaid|MEDICAID|0.10||||||| 9583857|ERX|0250|POTASSIUM CHLORIDE O/S 20|Cigna|CIGNA|||||0.10||| 9583857|ERX|0250|POTASSIUM CHLORIDE O/S 20|Humana Medicare Advantage|HUMANA MA|0.10||||||| 9583857|ERX|0250|POTASSIUM CHLORIDE O/S 20|Medicare|MEDICARE ACUTE|0.10||||0.10||| 9583857|ERX|0250|POTASSIUM CHLORIDE O/S 20|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.10||||||| 9583865|ERX|0250|GUAIFENSEIN 200MG/10ML 10|Medicaid|MEDICAID|0.10||||||| 9583865|ERX|0250|GUAIFENSEIN 200MG/10ML 10|Medicare|MEDICARE ACUTE|0.10||||||| 9583949|ERX|0250|FOSINOPRIL 10MG TABLET|NON CONTRACTED|COMMERCIAL OTHER 1|0.10||||||| 9584012|ERX|0250|HEMOCYTE PLUS CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|0.10||||||| 9584012|ERX|0250|HEMOCYTE PLUS CAPSULE|Blue Cross HMO Specialty|BCBSTX HMO|0.10||||||| 9584012|ERX|0250|HEMOCYTE PLUS CAPSULE|Medicare|MEDICARE ACUTE|0.10||||||| 9584046|ERX|0250|QUINAPRIL 10MG TABLET|Medicare|MEDICARE ACUTE|0.10||||||| 9584087|ERX|0250|IRBESARTAN 150MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|||||24.25||| 9584087|ERX|0250|IRBESARTAN 150MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|24.25||||||| 9584210|ERX|0250|LIRAGLUTIDE 3ML PEN|Medicare|MEDICARE ACUTE|880.25||||||| 9584335|ERX|0250|GENTAMICIN 120MG/100ML NS|Blue Cross PPO Specialty|BCBSTX PPO|95.75||||||| 9584335|ERX|0250|GENTAMICIN 120MG/100ML NS|Managed Medicaid|MEDICAID AMERIGROUP|95.75||||||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|NON CONTRACTED|COMMERCIAL OTHER 1|0.10||||||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Rusk State Hospital|RUSK STATE HOSP|0.10||||||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Medicare|MEDICARE ACUTE|0.10||||||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Tricare|TRICARE EAST REGION|0.10||||||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Managed Medicare|HEALTHSPRING MA|0.10||||||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Medicaid|MEDICAID HMO|||||0.10||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Managed Medicaid|MEDICAID SUPERIOR|0.10||||0.10||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Managed Medicaid|MEDICAID AMERIGROUP|0.10||||0.10||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|United Healthcare|UNITED HEALTHCARE OTHER|0.10||||||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.10||||||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Workers Compensation|WORKERS COMPENSATION OTHER|0.10||||||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.10||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Aenta Medicare Advantage|AETNA MEDICARE MA|0.10||||||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Blue Cross PPO Specialty|BCBSTX PPO|0.10||||||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Blue Cross HMO Specialty|BCBSTX HMO|0.10||||0.10||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.10||||||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Cigna|CIGNA|||||0.10||| 9584558|ERX|0250|CALCIUM CARBONATE 500MG C|Humana Medicare Advantage|HUMANA MA|0.10||||||| 9584616|ERX|0250|FUROSEMIDE 40MG/5ML ORAL|Aenta Medicare Advantage|AETNA MEDICARE MA|||||0.14||| 9584640|ERX|0250|DEXTROSE 5% NS KCI 40MEQ|Medicare|MEDICARE ACUTE|95.75||||||| 9584814|ERX|0250|LANOLIN 7G TUBE|Medicaid|MEDICAID|12.50||||||| 9584814|ERX|0250|LANOLIN 7G TUBE|United Healthcare|UNITED HEALTHCARE|12.50||||||| 9584814|ERX|0250|LANOLIN 7G TUBE|United Healthcare|UNITED HEALTHCARE OTHER|12.50||||||| 9584814|ERX|0250|LANOLIN 7G TUBE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|12.50||||||| 9584814|ERX|0250|LANOLIN 7G TUBE|Blue Cross PPO Specialty|BCBSTX PPO|12.50||||||| 9584814|ERX|0250|LANOLIN 7G TUBE|Managed Medicaid|MEDICAID SUPERIOR|12.50||||||| 9584814|ERX|0250|LANOLIN 7G TUBE|Managed Medicaid|MEDICAID AMERIGROUP|12.50||||||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|0.27||||||| 9584830|ERX|0250|APIXABAN 5MG TABLET|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.27||||||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.27||||||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Humana Medicare Advantage|HUMANA MA|0.27||||||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Cigna|CIGNA|0.27||||||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.27||||||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|0.27||||||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Rusk State Hospital|RUSK STATE HOSP|0.27||||||| 9584830|ERX|0250|APIXABAN 5MG TABLET|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.27||| 9584830|ERX|0250|APIXABAN 5MG TABLET|United Healthcare|UNITED HEALTHCARE|0.27||||||| 9584830|ERX|0250|APIXABAN 5MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|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|Veterans Affairs|VETERANS ADMINISTRATION|0.27||||||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|0.27||||||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.27||| 9584830|ERX|0250|APIXABAN 5MG TABLET|Medicare|MEDICARE ACUTE|0.27||||0.27||| 9584848|ERX|0250|APIXABAN 2.5MG TABLET|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.27||||||| 9584848|ERX|0250|APIXABAN 2.5MG TABLET|Aenta Medicare Advantage|AETNA MEDICARE MA|0.27||||||| 9584848|ERX|0250|APIXABAN 2.5MG TABLET|Humana Medicare Advantage|HUMANA MA|0.27||||0.27||| 9584848|ERX|0250|APIXABAN 2.5MG TABLET|Medicare|MEDICARE ACUTE|0.27||||||| 9584871|ERX|0250|AMINOPHYLLINE 500MG/20ML|NON CONTRACTED|COMMERCIAL OTHER 1|19.75||||||| 9584939|ERX|0250|AMIODARONE 150MG/100ML PR|United Medicare Advantage|AARP UHC WEST COMPLETE MA|2.21||||||| 9584939|ERX|0250|AMIODARONE 150MG/100ML PR|Humana Medicare Advantage|HUMANA MA|2.21||||||| 9584939|ERX|0250|AMIODARONE 150MG/100ML PR|Managed Medicare|HEALTHSPRING MA|2.21||||||| 9584939|ERX|0250|AMIODARONE 150MG/100ML PR|Medicare|MEDICARE ACUTE|2.21||||2.21||| 9584939|ERX|0250|AMIODARONE 150MG/100ML PR|Blue Cross PPO Specialty|BCBSTX PPO|||||2.21||| 9584962|ERX|0250|DERMOPLAST SPRAY, 2.75 OZ|Tricare|TRICARE EAST REGION|0.38||||||| 9584962|ERX|0250|DERMOPLAST SPRAY, 2.75 OZ|Managed Medicaid|MEDICAID SUPERIOR|0.38||||||| 9584962|ERX|0250|DERMOPLAST SPRAY, 2.75 OZ|United Healthcare|UNITED HEALTHCARE|0.38||||||| 9584962|ERX|0250|DERMOPLAST SPRAY, 2.75 OZ|Medicaid|MEDICAID|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 UNITED HEALTHCARE|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 HMO Specialty|BCBSTX HMO|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 UHSS UT HLTH|0.38||||||| 9584996|ERX|0250|OXYTOCIN 20 UNITS/1000 ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|95.75||||||| 9584996|ERX|0250|OXYTOCIN 20 UNITS/1000 ML|United Healthcare|UNITED HEALTHCARE OTHER|95.75||||||| 9584996|ERX|0250|OXYTOCIN 20 UNITS/1000 ML|United Healthcare|UNITED HEALTHCARE|95.75||||||| 9584996|ERX|0250|OXYTOCIN 20 UNITS/1000 ML|Managed Medicaid|MEDICAID SUPERIOR|95.75||||||| 9584996|ERX|0250|OXYTOCIN 20 UNITS/1000 ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|95.75||||95.75||| 9584996|ERX|0250|OXYTOCIN 20 UNITS/1000 ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|95.75||||||| 9584996|ERX|0250|OXYTOCIN 20 UNITS/1000 ML|Medicaid|MEDICAID|95.75||||||| 9584996|ERX|0250|OXYTOCIN 20 UNITS/1000 ML|NON CONTRACTED|COMMERCIAL OTHER 1|95.75||||||| 9584996|ERX|0250|OXYTOCIN 20 UNITS/1000 ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|95.75||||||| 9584996|ERX|0250|OXYTOCIN 20 UNITS/1000 ML|Tricare|TRICARE EAST REGION|95.75||||||| 9584996|ERX|0250|OXYTOCIN 20 UNITS/1000 ML|Managed Medicaid|MEDICAID AMERIGROUP|95.75||||||| 9584996|ERX|0250|OXYTOCIN 20 UNITS/1000 ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|95.75||||||| 9584996|ERX|0250|OXYTOCIN 20 UNITS/1000 ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|95.75||||||| 9584996|ERX|0250|OXYTOCIN 20 UNITS/1000 ML|Blue Cross HMO Specialty|BCBSTX HMO|95.75||||||| 9584996|ERX|0250|OXYTOCIN 20 UNITS/1000 ML|Blue Cross PPO Specialty|BCBSTX PPO|95.75||||||| 9585001|ERX|0250|AMOXICILLIN ORAL 250MG/5|Managed Medicaid|MEDICAID AMERIGROUP|||||0.10||| 9585001|ERX|0250|AMOXICILLIN ORAL 250MG/5|Managed Medicaid|MEDICAID SUPERIOR|0.10||||0.10||| 9585001|ERX|0250|AMOXICILLIN ORAL 250MG/5|Medicaid|MEDICAID HMO|||||0.10||| 9585001|ERX|0250|AMOXICILLIN ORAL 250MG/5|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||0.10||| 9585001|ERX|0250|AMOXICILLIN ORAL 250MG/5|Medicaid|MEDICAID|||||0.10||| 9585001|ERX|0250|AMOXICILLIN ORAL 250MG/5|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.10||| 9585001|ERX|0250|AMOXICILLIN ORAL 250MG/5|Blue Cross PPO Specialty|BCBSTX PPO|||||0.10||| 9585019|ERX|0250|GI COCKTAIL- JACKSONVILLE|Veterans Affairs|VETERANS ADMINISTRATION|||||125.86||| 9585019|ERX|0250|GI COCKTAIL- JACKSONVILLE|United Healthcare|UNITED HEALTHCARE|||||125.86||| 9585019|ERX|0250|GI COCKTAIL- JACKSONVILLE|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||125.86||| 9585019|ERX|0250|GI COCKTAIL- JACKSONVILLE|United Healthcare|UNITED HEALTHCARE|125.86||||||| 9585019|ERX|0250|GI COCKTAIL- JACKSONVILLE|United Healthcare|UNITED HEALTHCARE OTHER|||||125.86||| 9585019|ERX|0250|GI COCKTAIL- JACKSONVILLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|125.86||||125.86||| 9585019|ERX|0250|GI COCKTAIL- JACKSONVILLE|United Medicare Advantage|UHC MEDICARE GOLD MA|125.86||||125.86||| 9585019|ERX|0250|GI COCKTAIL- JACKSONVILLE|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||125.86||| 9585019|ERX|0250|GI COCKTAIL- JACKSONVILLE|Humana Medicare Advantage|HUMANA MA|125.86||||125.86||| 9585019|ERX|0250|GI COCKTAIL- JACKSONVILLE|Cigna|CIGNA|||||125.86||| 9585019|ERX|0250|GI COCKTAIL- JACKSONVILLE|Aetna|AETNA OTHER|||||125.86||| 9585019|ERX|0250|GI COCKTAIL- JACKSONVILLE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||125.86||| 9585019|ERX|0250|GI COCKTAIL- JACKSONVILLE|NON CONTRACTED|COMMERCIAL OTHER 1|||||125.86||| 9585019|ERX|0250|GI COCKTAIL- JACKSONVILLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||125.86||| 9585019|ERX|0250|GI COCKTAIL- JACKSONVILLE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||125.86||| 9585019|ERX|0250|GI COCKTAIL- JACKSONVILLE|Managed Medicaid|MEDICAID SUPERIOR|125.86||||125.86||| 9585019|ERX|0250|GI COCKTAIL- JACKSONVILLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||125.86||| 9585019|ERX|0250|GI COCKTAIL- JACKSONVILLE|Managed Medicaid|MEDICAID AMERIGROUP|||||125.86||| 9585019|ERX|0250|GI COCKTAIL- JACKSONVILLE|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||125.86||| 9585019|ERX|0250|GI COCKTAIL- JACKSONVILLE|Medicare|MEDICARE ACUTE|125.86||||125.86||| 9585019|ERX|0250|GI COCKTAIL- JACKSONVILLE|Medicaid|MEDICAID|||||125.86||| 9585019|ERX|0250|GI COCKTAIL- JACKSONVILLE|Tricare|TRICARE EAST REGION|||||125.86||| 9585019|ERX|0250|GI COCKTAIL- JACKSONVILLE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||125.86||| 9585019|ERX|0250|GI COCKTAIL- JACKSONVILLE|Blue Cross PPO Specialty|BCBSTX PPO|||||125.86||| 9585019|ERX|0250|GI COCKTAIL- JACKSONVILLE|Blue Cross HMO Specialty|BCBSTX HMO|||||125.86||| 9585019|ERX|0250|GI COCKTAIL- JACKSONVILLE|Aetna|AETNA PPO|||||125.86||| 9585019|ERX|0250|GI COCKTAIL- JACKSONVILLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||125.86||| 9585019|ERX|0250|GI COCKTAIL- JACKSONVILLE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||125.86||| 9585027|ERX|0250|TOPICAL ANESTHETIC SOLUTI|Veterans Affairs|VETERANS ADMINISTRATION|27.50||||||| 9585043|ERX|0250|MAGNESIUM SELF 4 GM/50ML|Managed Medicare|HEALTHSPRING MA|97.25||||||| 9585043|ERX|0250|MAGNESIUM SELF 4 GM/50ML|Managed Medicaid|MEDICAID AMERIGROUP|97.25||||97.25||| 9585043|ERX|0250|MAGNESIUM SELF 4 GM/50ML|Medicare|MEDICARE ACUTE|97.25||||97.25||| 9585043|ERX|0250|MAGNESIUM SELF 4 GM/50ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|97.25||||||| 9585043|ERX|0250|MAGNESIUM SELF 4 GM/50ML|Blue Cross HMO Specialty|BCBSTX HMO|97.25||||97.25||| 9585043|ERX|0250|MAGNESIUM SELF 4 GM/50ML|Aetna|AETNA OTHER|97.25||||||| 9585043|ERX|0250|MAGNESIUM SELF 4 GM/50ML|Rusk State Hospital|RUSK STATE HOSP|97.25||||||| 9585043|ERX|0250|MAGNESIUM SELF 4 GM/50ML|Blue Cross PPO Specialty|BCBSTX PPO|97.25||||97.25||| 9585043|ERX|0250|MAGNESIUM SELF 4 GM/50ML|Aenta Medicare Advantage|AETNA MEDICARE MA|97.25||||||| 9585043|ERX|0250|MAGNESIUM SELF 4 GM/50ML|Humana Medicare Advantage|HUMANA MA|97.25||||||| 9585043|ERX|0250|MAGNESIUM SELF 4 GM/50ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|97.25||||||| 9585043|ERX|0250|MAGNESIUM SELF 4 GM/50ML|Cigna|CIGNA|||||97.25||| 9585043|ERX|0250|MAGNESIUM SELF 4 GM/50ML|Veterans Affairs|VETERANS ADMINISTRATION|97.25||||||| 9585043|ERX|0250|MAGNESIUM SELF 4 GM/50ML|United Healthcare|UNITED HEALTHCARE|97.25||||||| 9585043|ERX|0250|MAGNESIUM SELF 4 GM/50ML|Medicaid|MEDICAID|97.25||||||| 9585043|ERX|0250|MAGNESIUM SELF 4 GM/50ML|United Medicare Advantage|UHC MEDICARE GOLD MA|97.25||||||| 9585043|ERX|0250|MAGNESIUM SELF 4 GM/50ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|97.25||||||| 9585043|ERX|0250|MAGNESIUM SELF 4 GM/50ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|97.25||||||| 9585043|ERX|0250|MAGNESIUM SELF 4 GM/50ML|Managed Medicaid|MEDICAID SUPERIOR|97.25||||||| 9585043|ERX|0250|MAGNESIUM SELF 4 GM/50ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|97.25||||97.25||| 9585043|ERX|0250|MAGNESIUM SELF 4 GM/50ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|97.25||||||| 9585043|ERX|0250|MAGNESIUM SELF 4 GM/50ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|97.25||||||| 9585068|ERX|0636||Medicare|MEDICARE ACUTE|2.42||||||| 9585068|ERX|0250|PAMIDRONATE 90MG/10ML SDV|Medicare|MEDICARE ACUTE|2.42||||||| 9585092|ERX|0250|ARMODAFINIL 50MG TAB|United Medicare Advantage|UHC MEDICARE GOLD MA|40.25||||||| 9585118|ERX|0250|LIDOCAINE 2%, 10ML MDV|Managed Medicare|BCBS MEDICARE PPO MA|||||28.25||| 9585118|ERX|0250|LIDOCAINE 2%, 10ML MDV|Managed Medicare|HEALTHSPRING MA|28.25||||28.25||| 9585118|ERX|0250|LIDOCAINE 2%, 10ML MDV|Managed Medicaid|MEDICAID AMERIGROUP|28.25||||28.25||| 9585118|ERX|0250|LIDOCAINE 2%, 10ML MDV|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|28.25||||28.25||| 9585118|ERX|0250|LIDOCAINE 2%, 10ML MDV|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||28.25||| 9585118|ERX|0250|LIDOCAINE 2%, 10ML MDV|Medicare|MEDICARE ACUTE|28.25||||28.25||| 9585118|ERX|0250|LIDOCAINE 2%, 10ML MDV|NON CONTRACTED|COMMERCIAL OTHER 1|28.25||||28.25||| 9585118|ERX|0250|LIDOCAINE 2%, 10ML MDV|Cigna|CIGNA|||||28.25||| 9585118|ERX|0250|LIDOCAINE 2%, 10ML MDV|Cigna|CIGNA|28.25||||28.25||| 9585118|ERX|0250|LIDOCAINE 2%, 10ML MDV|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|28.25||||28.25||| 9585118|ERX|0250|LIDOCAINE 2%, 10ML MDV|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||28.25||| 9585118|ERX|0250|LIDOCAINE 2%, 10ML MDV|Access Direct Platinum|HEALTHFIRST TPA UMR|||||28.25||| 9585118|ERX|0250|LIDOCAINE 2%, 10ML MDV|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||28.25||| 9585118|ERX|0250|LIDOCAINE 2%, 10ML MDV|Managed Medicaid|MEDICAID SUPERIOR|28.25||||28.25||| 9585118|ERX|0250|LIDOCAINE 2%, 10ML MDV|Humana Medicare Advantage|HUMANA MA|28.25||||28.25||| 9585118|ERX|0250|LIDOCAINE 2%, 10ML MDV|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|28.25||||28.25||| 9585118|ERX|0250|LIDOCAINE 2%, 10ML MDV|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|28.25||||28.25||| 9585118|ERX|0250|LIDOCAINE 2%, 10ML MDV|Aenta Medicare Advantage|AETNA MEDICARE MA|28.25||||28.25||| 9585118|ERX|0250|LIDOCAINE 2%, 10ML MDV|Blue Cross HMO Specialty|BCBSTX HMO|28.25||||28.25||| 9585118|ERX|0250|LIDOCAINE 2%, 10ML MDV|Medicaid|MEDICAID|28.25||||28.25||| 9585118|ERX|0250|LIDOCAINE 2%, 10ML MDV|Aetna|AETNA PPO|||||28.25||| 9585118|ERX|0250|LIDOCAINE 2%, 10ML MDV|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||28.25||| 9585118|ERX|0250|LIDOCAINE 2%, 10ML MDV|Aetna|AETNA OTHER|||||28.25||| 9585118|ERX|0250|LIDOCAINE 2%, 10ML MDV|Blue Cross PPO Specialty|BCBSTX OTHER|||||28.25||| 9585118|ERX|0250|LIDOCAINE 2%, 10ML MDV|Blue Cross PPO Specialty|BCBSTX PPO|28.25||||28.25||| 9585118|ERX|0250|LIDOCAINE 2%, 10ML MDV|Workers Compensation|WORKERS COMPENSATION OTHER|28.25||||28.25||| 9585118|ERX|0250|LIDOCAINE 2%, 10ML MDV|Veterans Affairs|VETERANS ADMINISTRATION|28.25||||||| 9585118|ERX|0250|LIDOCAINE 2%, 10ML MDV|Managed Medicaid|MEDICAID UNITED HEALTHCARE|28.25||||28.25||| 9585118|ERX|0250|LIDOCAINE 2%, 10ML MDV|United Healthcare|UNITED HEALTHCARE|||||28.25||| 9585118|ERX|0250|LIDOCAINE 2%, 10ML MDV|United Healthcare|UMR UNITED MEDICAL RESOURCES|28.25||||||| 9585118|ERX|0250|LIDOCAINE 2%, 10ML MDV|United Healthcare|UNITED HEALTHCARE OTHER|28.25||||28.25||| 9585118|ERX|0250|LIDOCAINE 2%, 10ML MDV|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||28.25||| 9585118|ERX|0250|LIDOCAINE 2%, 10ML MDV|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||28.25||| 9585118|ERX|0250|LIDOCAINE 2%, 10ML MDV|United Medicare Advantage|UHC MEDICARE GOLD MA|28.25||||28.25||| 9585118|ERX|0250|LIDOCAINE 2%, 10ML MDV|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|28.25||||28.25||| 9585118|ERX|0250|LIDOCAINE 2%, 10ML MDV|United Medicare Advantage|AARP UHC WEST COMPLETE MA|28.25||||28.25||| 9585118|ERX|0250|LIDOCAINE 2%, 10ML MDV|Tricare|TRICARE EAST REGION|28.25||||28.25||| 9585118|ERX|0250|LIDOCAINE 2%, 10ML MDV|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|28.25||||28.25||| 9585126|ERX|0250|GENTAMICIN 100MG/100ML NS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||95.75||| 9585126|ERX|0250|GENTAMICIN 100MG/100ML NS|NON CONTRACTED|COMMERCIAL OTHER 1|95.75||||||| 9585126|ERX|0250|GENTAMICIN 100MG/100ML NS|Managed Medicaid|MEDICAID SUPERIOR|95.75||||95.75||| 9585126|ERX|0250|GENTAMICIN 100MG/100ML NS|Managed Medicaid|MEDICAID AMERIGROUP|95.75||||||| 9585134|ERX|0250|AZITHROMYCIN ORAL 200MG/5|Managed Medicaid|MEDICAID SUPERIOR|0.38||||0.38||| 9585134|ERX|0250|AZITHROMYCIN ORAL 200MG/5|Managed Medicaid|MEDICAID AMERIGROUP|||||0.38||| 9585134|ERX|0250|AZITHROMYCIN ORAL 200MG/5|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.38||| 9585134|ERX|0250|AZITHROMYCIN ORAL 200MG/5|Medicaid|MEDICAID|0.38||||0.38||| 9585134|ERX|0250|AZITHROMYCIN ORAL 200MG/5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.38||| 9585134|ERX|0250|AZITHROMYCIN ORAL 200MG/5|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||0.38||| 9585142|ERX|0250|CEFPROZIL ORAL 250MG/5ML|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||0.31||| 9585142|ERX|0250|CEFPROZIL ORAL 250MG/5ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.31||| 9585142|ERX|0250|CEFPROZIL ORAL 250MG/5ML|Blue Cross PPO Specialty|BCBSTX PPO|||||0.31||| 9585142|ERX|0250|CEFPROZIL ORAL 250MG/5ML|Tricare|TRICARE EAST REGION|||||0.31||| 9585142|ERX|0250|CEFPROZIL ORAL 250MG/5ML|Managed Medicaid|MEDICAID SUPERIOR|||||0.31||| 9585142|ERX|0250|CEFPROZIL ORAL 250MG/5ML|Managed Medicaid|MEDICAID AMERIGROUP|||||0.31||| 9585142|ERX|0250|CEFPROZIL ORAL 250MG/5ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.31||| 9585142|ERX|0250|CEFPROZIL ORAL 250MG/5ML|Medicaid|MEDICAID|||||0.31||| 9585142|ERX|0250|CEFPROZIL ORAL 250MG/5ML|Medicaid|MEDICAID TEXAS CHILDRENS|||||0.31||| 9585159|ERX|0250|AZTREONAM 2 G NS MB+|Managed Medicare|HEALTHSPRING MA|391.50||||||| 9585159|ERX|0250|AZTREONAM 2 G NS MB+|Managed Medicaid|MEDICAID SUPERIOR|391.50||||||| 9585159|ERX|0250|AZTREONAM 2 G NS MB+|Medicare|MEDICARE ACUTE|391.50||||||| 9585159|ERX|0250|AZTREONAM 2 G NS MB+|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||391.50||| 9585159|ERX|0250|AZTREONAM 2 G NS MB+|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|391.50||||||| 9585159|ERX|0250|AZTREONAM 2 G NS MB+|United Medicare Advantage|AARP UHC WEST COMPLETE MA|391.50||||||| 9585167|ERX|0250|MISOPROSTOL 25 MCG (1/4-1|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.10||||||| 9585167|ERX|0250|MISOPROSTOL 25 MCG (1/4-1|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.10||||||| 9585167|ERX|0250|MISOPROSTOL 25 MCG (1/4-1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.10||||||| 9585167|ERX|0250|MISOPROSTOL 25 MCG (1/4-1|United Healthcare|UNITED HEALTHCARE|0.10||||||| 9585167|ERX|0250|MISOPROSTOL 25 MCG (1/4-1|Blue Cross PPO Specialty|BCBSTX PPO|0.10||||||| 9585167|ERX|0250|MISOPROSTOL 25 MCG (1/4-1|NON CONTRACTED|COMMERCIAL OTHER 1|0.10||||||| 9585167|ERX|0250|MISOPROSTOL 25 MCG (1/4-1|Tricare|TRICARE EAST REGION|0.10||||||| 9585167|ERX|0250|MISOPROSTOL 25 MCG (1/4-1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.10||||||| 9585167|ERX|0250|MISOPROSTOL 25 MCG (1/4-1|Managed Medicaid|MEDICAID SUPERIOR|0.10||||||| 9585167|ERX|0250|MISOPROSTOL 25 MCG (1/4-1|Managed Medicaid|MEDICAID AMERIGROUP|0.10||||||| 9585167|ERX|0250|MISOPROSTOL 25 MCG (1/4-1|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.10||||||| 9585167|ERX|0250|MISOPROSTOL 25 MCG (1/4-1|Medicaid|MEDICAID|0.10||||||| 9585183|ERX|0250|MAGNESIUM SULFATE 40G/100|Managed Medicaid|MEDICAID AMERIGROUP|95.75||||95.75||| 9585183|ERX|0250|MAGNESIUM SULFATE 40G/100|Medicaid|MEDICAID|95.75||||||| 9585183|ERX|0250|MAGNESIUM SULFATE 40G/100|Blue Cross PPO Specialty|BCBSTX PPO|95.75||||95.75||| 9585183|ERX|0250|MAGNESIUM SULFATE 40G/100|Blue Cross HMO Specialty|BCBSTX HMO|95.75||||95.75||| 9585183|ERX|0250|MAGNESIUM SULFATE 40G/100|NON CONTRACTED|COMMERCIAL OTHER 2|95.75||||||| 9585183|ERX|0250|MAGNESIUM SULFATE 40G/100|Managed Medicaid|MEDICAID SUPERIOR|95.75||||95.75||| 9585183|ERX|0250|MAGNESIUM SULFATE 40G/100|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|95.75||||||| 9585183|ERX|0250|MAGNESIUM SULFATE 40G/100|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||95.75||| 9585233|ERX|0250|FLUTICASONE 110 MCG INHAL|Medicare|MEDICARE ACUTE|1,302.25||||||| 9585233|ERX|0250|FLUTICASONE 110 MCG INHAL|Humana Medicare Advantage|HUMANA MA|1,302.25||||||| 9585233|ERX|0250|FLUTICASONE 110 MCG INHAL|United Medicare Advantage|UHC MEDICARE GOLD MA|1,302.25||||||| 9585274|ERX|0250|VANCOMYCIN 750 MG VIAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|39.50||||||| 9585274|ERX|0250|VANCOMYCIN 750 MG VIAL|Medicaid|MEDICAID|39.50||||||| 9585274|ERX|0250|VANCOMYCIN 750 MG VIAL|United Medicare Advantage|UHC MEDICARE GOLD MA|39.50||||||| 9585282|ERX|0250|VANCOMYCIN 750 MG IN 100M|Medicare|MEDICARE ACUTE|95.75||||||| 9585282|ERX|0250|VANCOMYCIN 750 MG IN 100M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|95.75||||||| 9585282|ERX|0250|VANCOMYCIN 750 MG IN 100M|Managed Medicare|HEALTHSPRING MA|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|United Medicare Advantage|UHC MEDICARE GOLD MA|95.75||||||| 9585423|ERX|0250|FLOVENT 220 MCG INHALER|Workers Compensation|WORKERS COMPENSATION OTHER|2,022.50||||||| 9585423|ERX|0250|FLOVENT 220 MCG INHALER|United Medicare Advantage|UHC MEDICARE GOLD MA|2,022.50||||||| 9585555|ERX|0250|DESFLURANE, 240 ML|Managed Medicare|HEALTHSPRING MA|877.50||||||| 9585555|ERX|0250|DESFLURANE, 240 ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|877.50||||877.50||| 9585555|ERX|0250|DESFLURANE, 240 ML|Managed Medicaid|MEDICAID AMERIGROUP|877.50||||877.50||| 9585555|ERX|0250|DESFLURANE, 240 ML|Medicare|MEDICARE ACUTE|877.50||||877.50||| 9585555|ERX|0250|DESFLURANE, 240 ML|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|877.50||||||| 9585555|ERX|0250|DESFLURANE, 240 ML|Tricare|TRICARE EAST REGION|||||877.50||| 9585555|ERX|0250|DESFLURANE, 240 ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||877.50||| 9585555|ERX|0250|DESFLURANE, 240 ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|877.50||||877.50||| 9585555|ERX|0250|DESFLURANE, 240 ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||877.50||| 9585555|ERX|0250|DESFLURANE, 240 ML|Aenta Medicare Advantage|AETNA MEDICARE MA|877.50||||877.50||| 9585555|ERX|0250|DESFLURANE, 240 ML|Medicaid|MEDICAID|877.50||||877.50||| 9585555|ERX|0250|DESFLURANE, 240 ML|Managed Medicaid|MEDICAID SUPERIOR|877.50||||877.50||| 9585555|ERX|0250|DESFLURANE, 240 ML|Blue Cross HMO Specialty|BCBSTX HMO|||||877.50||| 9585555|ERX|0250|DESFLURANE, 240 ML|NON CONTRACTED|COMMERCIAL OTHER 1|877.50||||877.50||| 9585555|ERX|0250|DESFLURANE, 240 ML|Medicare|MEDICARE PART B ONLY IP|||||877.50||| 9585555|ERX|0250|DESFLURANE, 240 ML|Aetna|AETNA PPO|877.50||||877.50||| 9585555|ERX|0250|DESFLURANE, 240 ML|Blue Cross PPO Specialty|BCBSTX PPO|877.50||||877.50||| 9585555|ERX|0250|DESFLURANE, 240 ML|Humana Medicare Advantage|HUMANA MA|877.50||||877.50||| 9585555|ERX|0250|DESFLURANE, 240 ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||877.50||| 9585555|ERX|0250|DESFLURANE, 240 ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||877.50||| 9585555|ERX|0250|DESFLURANE, 240 ML|Cigna|CIGNA|||||877.50||| 9585555|ERX|0250|DESFLURANE, 240 ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|877.50||||||| 9585555|ERX|0250|DESFLURANE, 240 ML|Veterans Affairs|VETERANS ADMINISTRATION|877.50||||||| 9585555|ERX|0250|DESFLURANE, 240 ML|United Healthcare|UNITED HEALTHCARE|877.50||||||| 9585555|ERX|0250|DESFLURANE, 240 ML|Workers Compensation|WORKERS COMPENSATION OTHER|||||877.50||| 9585555|ERX|0250|DESFLURANE, 240 ML|United Healthcare|UMR UNITED MEDICAL RESOURCES|877.50||||||| 9585555|ERX|0250|DESFLURANE, 240 ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|877.50||||877.50||| 9585555|ERX|0250|DESFLURANE, 240 ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|877.50||||877.50||| 9585555|ERX|0250|DESFLURANE, 240 ML|United Healthcare|UNITED HEALTHCARE OTHER|||||877.50||| 9585555|ERX|0250|DESFLURANE, 240 ML|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||877.50||| 9585555|ERX|0250|DESFLURANE, 240 ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|877.50||||877.50||| 9585555|ERX|0250|DESFLURANE, 240 ML|United Medicare Advantage|UHC MEDICARE GOLD MA|877.50||||877.50||| 9586090|ERX|0250|CLINIMIX 4.25%-5%, 1000ML|Veterans Affairs|VETERANS ADMINISTRATION|1.92||||||| 9586090|ERX|0250|CLINIMIX 4.25%-5%, 1000ML|Medicare|MEDICARE ACUTE|1.92||||||| 9586322|ERX|0250|NIFEDIPINE XL 30MG TABLET|Managed Medicare|HEALTHSPRING MA|9.75||||||| 9586322|ERX|0250|NIFEDIPINE XL 30MG TABLET|Managed Medicaid|MEDICAID SUPERIOR|9.75||||9.75||| 9586322|ERX|0250|NIFEDIPINE XL 30MG TABLET|Managed Medicaid|MEDICAID AMERIGROUP|||||9.75||| 9586322|ERX|0250|NIFEDIPINE XL 30MG TABLET|Humana Medicare Advantage|HUMANA MA|9.75||||||| 9586322|ERX|0250|NIFEDIPINE XL 30MG TABLET|Blue Cross HMO Specialty|BCBSTX HMO|9.75||||||| 9586322|ERX|0250|NIFEDIPINE XL 30MG TABLET|Blue Cross PPO Specialty|BCBSTX PPO|9.75||||9.75||| 9586322|ERX|0250|NIFEDIPINE XL 30MG TABLET|United Medicare Advantage|AARP UHC WEST COMPLETE MA|9.75||||||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|United Healthcare|UMR UNITED MEDICAL RESOURCES|0.12||||||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Blue Cross HMO Specialty|BCBSTX HMO|||||0.12||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Blue Cross PPO Specialty|BCBSTX PPO|||||0.12||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||0.12||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Managed Medicare|HEALTHSPRING MA|||||0.12||| 9586348|ERX|0250|LIDO-MAALOX-BENADRYL 30ML|Managed Medicaid|MEDICAID SUPERIOR|0.12||||0.12||| 9586546|ERX|0250|ZENPEP 5000 CAPSULE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|13.02||||||| 9586546|ERX|0250|ZENPEP 5000 CAPSULE|Medicare|MEDICARE ACUTE|13.02||||||| 9586546|ERX|0250|ZENPEP 5000 CAPSULE|United Medicare Advantage|UHC MEDICARE GOLD MA|13.02||||||| 9586553|ERX|0250|CLINMIX E 5%-20%, 1000 ML|Humana Medicare Advantage|HUMANA MA|237.30||||||| 9586553|ERX|0250|CLINMIX E 5%-20%, 1000 ML|Managed Medicare|HEALTHSPRING MA|237.30||||||| 9586587|ERX|0250|OPIUM-BELLAD 16.2-30 MG S|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||137.60||| 9587338|ERX|0250|REMDESIVIR 100 MG VIAL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|6.50||||||| 9587338|ERX|0250|REMDESIVIR 100 MG VIAL|Rusk State Hospital|RUSK STATE HOSP|6.50||||||| 9587338|ERX|0250|REMDESIVIR 100 MG VIAL|Workers Compensation|WORKERS COMPENSATION OTHER|6.50||||||| 9587338|ERX|0250|REMDESIVIR 100 MG VIAL|Medicare|MEDICARE ACUTE|6.50||||||| 9587338|ERX|0250|REMDESIVIR 100 MG VIAL|Workers Compensation|UT EMPLOYEE INJURY|6.50||||||| 9587338|ERX|0250|REMDESIVIR 100 MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|6.50||||||| 9589193|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|Medicaid|MEDICAID|||||24.50||| 9589193|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|Managed Medicaid|MEDICAID SUPERIOR|||||24.50||| 9589193|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|Tricare|TRICARE EAST REGION|||||24.50||| 9589193|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|NON CONTRACTED|COMMERCIAL OTHER 1|24.50||||||| 9589193|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|24.50||||||| 9589193|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|Managed Medicaid|MEDICAID AMERIGROUP|24.50||||||| 9589193|ERX|0250|HYDROC-ACET 2.5-108MG/5ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|24.50||||||| 9589433|ERX|0250|K PHOSPHATE 3 MMOL/ML, 5|Medicare|MEDICARE ACUTE|103.08||||||| 9589433|ERX|0250|K PHOSPHATE 3 MMOL/ML, 5|UTMB|UTMB CORRECTIONAL MANAGED CARE|103.08||||||| 9589433|ERX|0250|K PHOSPHATE 3 MMOL/ML, 5|Managed Medicare|HEALTHSPRING MA|103.08||||||| 9589433|ERX|0250|K PHOSPHATE 3 MMOL/ML, 5|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|103.08||||||| 9589433|ERX|0250|K PHOSPHATE 3 MMOL/ML, 5|Aenta Medicare Advantage|AETNA MEDICARE MA|103.08||||||| 9589433|ERX|0250|K PHOSPHATE 3 MMOL/ML, 5|Blue Cross HMO Specialty|BCBSTX HMO|103.08||||||| 9589433|ERX|0250|K PHOSPHATE 3 MMOL/ML, 5|Humana Medicare Advantage|HUMANA MA|103.08||||||| 9589441|ERX|0250|SODIUM PHOSPHATE 3 MMOL/M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|103.08||||||| 9589441|ERX|0250|SODIUM PHOSPHATE 3 MMOL/M|Aenta Medicare Advantage|AETNA MEDICARE MA|103.08||||||| 9589441|ERX|0250|SODIUM PHOSPHATE 3 MMOL/M|Managed Medicare|HEALTHSPRING MA|103.08||||||| 9589441|ERX|0250|SODIUM PHOSPHATE 3 MMOL/M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|103.08||||||| 9589441|ERX|0250|SODIUM PHOSPHATE 3 MMOL/M|Medicare|MEDICARE ACUTE|103.08||||||| 9589441|ERX|0250|SODIUM PHOSPHATE 3 MMOL/M|Rusk State Hospital|RUSK STATE HOSP|103.08||||||| 9589540|ERX|0250|LEVETIRACETAM 500MG/5ML U|Blue Cross HMO Specialty|BCBSTX HMO|20.75||||||| 9589540|ERX|0250|LEVETIRACETAM 500MG/5ML U|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|20.75||||||| 9589565|ERX|0636||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,043.75||||||| 9590142|ERX|0250|BENZOCAINE ORAL SPRAY 0.5|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|70.50||||||| 9590142|ERX|0250|BENZOCAINE ORAL SPRAY 0.5|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||70.50||| 9590142|ERX|0250|BENZOCAINE ORAL SPRAY 0.5|Humana Medicare Advantage|HUMANA MA|70.50||||||| 9590142|ERX|0250|BENZOCAINE ORAL SPRAY 0.5|Blue Cross PPO Specialty|BCBSTX PPO|70.50||||||| 9590142|ERX|0250|BENZOCAINE ORAL SPRAY 0.5|Medicare|MEDICARE ACUTE|70.50||||||| 9590142|ERX|0250|BENZOCAINE ORAL SPRAY 0.5|Managed Medicaid|MEDICAID AMERIGROUP|||||70.50||| 9590241|ERX|0250|RIBAVIRIN 200MG CAPSULE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|59.75||||||| 9590241|ERX|0250|RIBAVIRIN 200MG CAPSULE|NON CONTRACTED|COMMERCIAL OTHER 1|59.75||||||| 9590241|ERX|0250|RIBAVIRIN 200MG CAPSULE|UTMB|UTMB CORRECTIONAL MANAGED CARE|59.75||||||| 9590241|ERX|0250|RIBAVIRIN 200MG CAPSULE|Rusk State Hospital|RUSK STATE HOSP|59.75||||||| 9590241|ERX|0250|RIBAVIRIN 200MG CAPSULE|Blue Cross PPO Specialty|BCBSTX PPO|59.75||||||| 9590241|ERX|0250|RIBAVIRIN 200MG CAPSULE|Aetna|AETNA PPO|59.75||||||| 9590241|ERX|0250|RIBAVIRIN 200MG CAPSULE|Medicare|MEDICARE ACUTE|59.75||||||| 9590241|ERX|0250|RIBAVIRIN 200MG CAPSULE|Humana Medicare Advantage|HUMANA MA|59.75||||||| 9590241|ERX|0250|RIBAVIRIN 200MG CAPSULE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|59.75||||||| 9590514|ERX|0250|VANCOMYCIN 1500MG IN 250M|UTMB|UTMB CORRECTIONAL MANAGED CARE|88.50||||||| 9590514|ERX|0250|VANCOMYCIN 1500MG IN 250M|Medicaid|MEDICAID|88.50||||||| 9590514|ERX|0250|VANCOMYCIN 1500MG IN 250M|Managed Medicaid|MEDICAID SUPERIOR|88.50||||||| 9590514|ERX|0250|VANCOMYCIN 1500MG IN 250M|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|88.50||||||| 9590514|ERX|0250|VANCOMYCIN 1500MG IN 250M|United Medicare Advantage|UHC MEDICARE GOLD MA|88.50||||||| 9590514|ERX|0250|VANCOMYCIN 1500MG IN 250M|Humana Medicare Advantage|HUMANA MA|88.50||||||| 9590522|ERX|0250|DEXMEDETOMIDINE 200MCG/50|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|346.75||||||| 9590522|ERX|0250|DEXMEDETOMIDINE 200MCG/50|Humana Medicare Advantage|HUMANA MA|346.75||||||| 9590522|ERX|0250|DEXMEDETOMIDINE 200MCG/50|Blue Cross PPO Specialty|BCBSTX PPO|346.75||||||| 9590522|ERX|0250|DEXMEDETOMIDINE 200MCG/50|Rusk State Hospital|RUSK STATE HOSP|346.75||||||| 96360|EAP|0260|IV INFUSE UP TO 1HR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||525.50||| 96360|EAP|0260|IV INFUSION HYDRATION UP|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||567.25||| 96360|EAP|0260|IV INFUSION HYDRATION UP|United Medicare Advantage|UHC MEDICARE GOLD MA|||||567.25||| 96360|EAP|0260|IV INFUSION HYDRATION UP|United Healthcare|UNITED HEALTHCARE|||||567.25||| 96360|EAP|0260|IV INFUSE UP TO 1HR|United Healthcare|UNITED HEALTHCARE OTHER|525.50||||525.50||| 96360|EAP|0260|IV INFUSE UP TO 1HR|United Healthcare|UNITED HEALTHCARE|||||525.50||| 96360|EAP|0260|IV INFUSION HYDRATION UP|Veterans Affairs|VETERANS ADMINISTRATION|||||567.25||| 96360|EAP|0260|IV INFUSION HYDRATION UP|Cigna|CIGNA|||||567.25||| 96360|EAP|0260|IV INFUSE UP TO 1HR|Cigna|CIGNA|||||525.50||| 96360|EAP|0260|IV INFUSION HYDRATION UP|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||567.25||| 96360|EAP|0260|IV INFUSION HYDRATION UP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||567.25||| 96360|EAP|0260|IV INFUSION HYDRATION UP|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|525.50||||567.25||| 96360|EAP|0260|IV INFUSION HYDRATION UP|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||567.25||| 96360|EAP|0260|IV INFUSE UP TO 1HR|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||525.50||| 96360|EAP|0260|IV INFUSION HYDRATION UP|Aenta Medicare Advantage|AETNA MEDICARE MA|||||567.25||| 96360|EAP|0260|IV INFUSION HYDRATION UP|Blue Cross HMO Specialty|BCBSTX HMO|567.25||||567.25||| 96360|EAP|0260|IV INFUSION HYDRATION UP|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||567.25||| 96360|EAP|0260|IV INFUSE UP TO 1HR|Blue Cross HMO Specialty|BCBSTX HMO|525.50||||525.50||| 96360|EAP|0260|IV INFUSION HYDRATION UP|Aetna|AETNA PPO|||||567.25||| 96360|EAP|0260|IV INFUSION HYDRATION UP|Blue Cross PPO Specialty|BCBSTX PPO|525.50||||567.25||| 96360|EAP|0260|IV INFUSION HYDRATION UP|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||567.25||| 96360|EAP|0260|IV INFUSE UP TO 1HR|Blue Cross PPO Specialty|BCBSTX PPO|525.50||||525.50||| 96360|EAP|0260|IV INFUSION HYDRATION UP|Blue Cross PPO Specialty|BCBSTX OTHER|||||567.25||| 96360|EAP|0260|IV INFUSION HYDRATION UP|NON CONTRACTED|COMMERCIAL OTHER 1|||||567.25||| 96360|EAP|0260|IV INFUSE UP TO 1HR|NON CONTRACTED|COMMERCIAL OTHER 2|525.50||||||| 96360|EAP|0260|IV INFUSION HYDRATION UP|Medicare|MEDICARE ACUTE|567.25||||567.25||| 96360|EAP|0260|IV INFUSE UP TO 1 HR|Medicare|MEDICARE ACUTE|567.25||||701.25||| 96360|EAP|0260|IV INFUSION HYDRATION UP|Rusk State Hospital|RUSK STATE HOSP|567.25||||567.25||| 96360|EAP|0260|IV INFUSION HYDRATION UP|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|567.25||||567.25||| 96360|EAP|0260|IV INFUSION HYDRATION UP|Humana Medicare Advantage|HUMANA MA|567.25||||567.25||| 96360|EAP|0260|IV INFUSION HYDRATION UP|Workers Compensation|WORKERS COMPENSATION OTHER|||||567.25||| 96360|EAP|0260|IV INFUSION HYDRATION UP|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||567.25||| 96360|EAP|0260|IV INFUSION HYDRATION UP|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||567.25||| 96360|EAP|0260|IV INFUSION HYDRATION UP|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||567.25||| 96360|EAP|0260|IV INFUSION HYDRATION UP|Medicaid|SUPERIOR HEALTHPLAN CHIP|525.50||||567.25||| 96360|EAP|0260|IV INFUSION HYDRATION UP|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||567.25||| 96360|EAP|0260|IV INFUSION HYDRATION UP|Medicaid|MEDICAID HMO|||||567.25||| 96360|EAP|0260|IV INFUSION HYDRATION UP|Medicaid|MEDICAID|525.50||||567.25||| 96360|EAP|0260|IV INFUSION HYDRATION UP|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||567.25||| 96360|EAP|0260|IV INFUSE UP TO 1HR|Medicaid|SUPERIOR HEALTHPLAN CHIP|525.50||||525.50||| 96360|EAP|0260|IV INFUSE UP TO 1HR|Medicaid|MEDICAID HMO|||||525.50||| 96360|EAP|0260|IV INFUSE UP TO 1HR|Medicaid|MEDICAID|525.50||||525.50||| 96360|EAP|0260|IV INFUSION HYDRATION UP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||567.25||| 96360|EAP|0260|IV INFUSION HYDRATION UP|Managed Medicaid|MEDICAID SUPERIOR|567.25||||567.25||| 96360|EAP|0260|IV INFUSION HYDRATION UP|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||567.25||| 96360|EAP|0260|IV INFUSION HYDRATION UP|Managed Medicaid|MEDICAID AMERIGROUP|525.50||||567.25||| 96360|EAP|0260|IV INFUSE UP TO 1HR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||525.50||| 96360|EAP|0260|IV INFUSION HYDRATION UP|Medicaid|MEDICAID PCCM|||||567.25||| 96360|EAP|0260|IV INFUSE UP TO 1HR|Managed Medicaid|MEDICAID SUPERIOR|525.50||||525.50||| 96360|EAP|0260|IV INFUSE UP TO 1HR|Managed Medicaid|MEDICAID AMERIGROUP|525.50||||525.50||| 96360|EAP|0260|IV INFUSE UP TO 1HR|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||525.50||| 96361|EAP|0260|IV INF HYDRATION EA ADL H|Managed Medicare|HEALTHSPRING MA|282.25||||282.25||| 96361|EAP|0260|IV INFUSE EA ADDL|Medicaid|SUPERIOR HEALTHPLAN CHIP|262.75||||282.25||| 96361|EAP|0260|IV INF HYDRATION EA ADL H|Medicaid|SUPERIOR HEALTHPLAN CHIP|282.25||||282.25||| 96361|EAP|0260|IV INF HYDRATION EA ADL H|Medicaid|MEDICAID PCCM|||||282.25||| 96361|EAP|0260|IV INFUSE EA ADDL|Medicaid|MEDICAID|262.75||||262.75||| 96361|EAP|0260|IV INF HYDRATION EA ADL H|Medicaid|MOLINA HEALTHCARE OF TEXAS|282.25||||282.25||| 96361|EAP|0260|IV INFUSE EA ADDL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|282.25||||262.75||| 96361|EAP|0260|IV INF HYDRATION EA ADL H|Managed Medicaid|MEDICAID UNITED HEALTHCARE|282.25||||282.25||| 96361|EAP|0260|IV INFUSE EA ADDL|Managed Medicaid|MEDICAID AMERIGROUP|262.75||||262.75||| 96361|EAP|0260|IV INF HYDRATION EA ADL H|Managed Medicaid|MEDICAID SUPERIOR|282.25||||282.25||| 96361|EAP|0260|IV INFUSE EA ADDL|NON CONTRACTED|COMMERCIAL OTHER 2|262.75||||||| 96361|EAP|0260|IV INF HYDRATION EA ADL H|NON CONTRACTED|COMMERCIAL OTHER 1|||||282.25||| 96361|EAP|0260|IV INF HYDRATION EA ADL H|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||282.25||| 96361|EAP|0260|IV INF HYDRATION EA ADL H|UTMB|UTMB CORRECTIONAL MANAGED CARE|282.25||||282.25||| 96361|EAP|0260|IV INF HYDRATION EA ADL H|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|282.25||||282.25||| 96361|EAP|0260|IV HYDRATION EACH HR UP T|Medicare|MEDICARE ACUTE|282.25||||349.25||| 96361|EAP|0260|IV INF HYDRATION EA ADL H|Aenta Medicare Advantage|AETNA MEDICARE MA|282.25||||282.25||| 96361|EAP|0260|IV INF HYDRATION EA ADL H|Rusk State Hospital|RUSK STATE HOSP|282.25||||282.25||| 96361|EAP|0260|IV INF HYDRATION EA ADL H|Tricare|TRICARE EAST REGION|||||282.25||| 96361|EAP|0260|IV INFUSE EA ADDL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||262.75||| 96361|EAP|0260|IV INF HYDRATION EA ADL H|Managed Medicaid|MEDICAID AMERIGROUP|262.75||||282.25||| 96361|EAP|0260|IV INF HYDRATION EA ADL H|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||282.25||| 96361|EAP|0260|IV INF HYDRATION EA ADL H|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|282.25||||282.25||| 96361|EAP|0260|IV INF HYDRATION EA ADL H|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|282.25||||282.25||| 96361|EAP|0260|IV INF HYDRATION EA ADL H|Blue Cross HMO Specialty|BCBSTX HMO|282.25||||282.25||| 96361|EAP|0260|IV INFUSE EA ADDL|Blue Cross HMO Specialty|BCBSTX HMO|262.75||||282.25||| 96361|EAP|0260|IV INFUSE EA ADDL|Managed Medicaid|MEDICAID SUPERIOR|262.75||||262.75||| 96361|EAP|0260|IV INF HYDRATION EA ADL H|Aetna|AETNA OTHER|282.25||||282.25||| 96361|EAP|0260|IV INF HYDRATION EA ADL H|Medicare|MEDICARE ACUTE|282.25||||282.25||| 96361|EAP|0260|IV INF HYDRATION EA ADL H|Aetna|AETNA PPO|282.25||||||| 96361|EAP|0260|IV INF HYDRATION EA ADL H|Blue Cross PPO Specialty|BCBSTX PPO|282.25||||282.25||| 96361|EAP|0260|IV INFUSE EA ADDL|Blue Cross PPO Specialty|BCBSTX PPO|262.75||||262.75||| 96361|EAP|0260|IV INF HYDRATION EA ADL H|Medicaid|MEDICAID|282.25||||282.25||| 96361|EAP|0260|IV INF HYDRATION EA ADL H|Blue Cross PPO Specialty|BCBSTX OTHER|||||282.25||| 96361|EAP|0260|IV INFUSE EA ADDL|Medicaid|MOLINA HEALTHCARE OF TEXAS|282.25||||262.75||| 96361|EAP|0260|IV INF HYDRATION EA ADL H|Humana Medicare Advantage|HUMANA MA|282.25||||282.25||| 96361|EAP|0260|IV INF HYDRATION EA ADL H|Cigna|CIGNA|||||282.25||| 96361|EAP|0260|IV INF HYDRATION EA ADL H|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|262.75||||282.25||| 96361|EAP|0260|IV INF HYDRATION EA ADL H|Medicaid|MEDICAID TEXAS CHILDRENS|||||282.25||| 96361|EAP|0260|IV INFUSE EA ADDL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|282.25||||262.75||| 96361|EAP|0260|IV INF HYDRATION EA ADL H|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||282.25||| 96361|EAP|0260|IV INF HYDRATION EA ADL H|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||282.25||| 96361|EAP|0260|IV INF HYDRATION EA ADL H|United Medicare Advantage|UHC MEDICARE GOLD MA|282.25||||282.25||| 96361|EAP|0260|IV INF HYDRATION EA ADL H|United Medicare Advantage|AARP UHC WEST COMPLETE MA|282.25||||282.25||| 96361|EAP|0260|IV INF HYDRATION EA ADL H|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|282.25||||282.25||| 96361|EAP|0260|IV INFUSE EA ADDL|United Healthcare|UNITED HEALTHCARE OTHER|||||262.75||| 96361|EAP|0260|IV INFUSE EA ADDL|United Healthcare|UNITED HEALTHCARE|282.25||||262.75||| 96361|EAP|0260|IV INF HYDRATION EA ADL H|United Healthcare|UNITED HEALTHCARE OTHER|||||282.25||| 96361|EAP|0260|IV INF HYDRATION EA ADL H|United Healthcare|UNITED HEALTHCARE|282.25||||282.25||| 96361|EAP|0260|IV INF HYDRATION EA ADL H|United Healthcare|UMR UNITED MEDICAL RESOURCES|282.25||||282.25||| 96361|EAP|0260|IV INF HYDRATION EA ADL H|United Healthcare|TML GROUP BENEFITS|282.25||||||| 96361|EAP|0260|IV INF HYDRATION EA ADL H|Veterans Affairs|VETERANS ADMINISTRATION|282.25||||282.25||| 96361|EAP|0260|IV INF HYDRATION EA ADL H|Workers Compensation|WORKERS COMPENSATION OTHER|282.25||||282.25||| 96365|EAP|0450|IV INF THER PROPH DX UP T|Workers Compensation|WORKERS COMPENSATION OTHER|477.25||||477.25||| 96365|EAP|0450|IV INF THER PROPH DX UP T|United Medicare Advantage|AARP UHC WEST COMPLETE MA|477.25||||477.25||| 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|477.25||||477.25||| 96365|EAP|0450|IV INF THER PROPH DX UP T|Veterans Affairs|VETERANS ADMINISTRATION|477.25||||477.25||| 96365|EAP|0450|IV INF THER PROPH DX UP T|United Healthcare|UNITED HEALTHCARE|477.25||||477.25||| 96365|EAP|0450|IV INF THER PROPH DX UP T|United Healthcare|UNITED HEALTHCARE|||||477.25||| 96365|EAP|0450|IV INF THER PROPH DX UP T|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||477.25||| 96365|EAP|0260|IV INFUSION 1ST HR THERAP|Humana Medicare Advantage|HUMANA MA|||||589.50||| 96365|EAP|0450|IV INF THER PROPH DX UP T|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||477.25||| 96365|EAP|0450|IV INF THER PROPH DX UP T|Blue Cross PPO Specialty|BCBSTX OTHER|477.25||||477.25||| 96365|EAP|0450|IV INF THER PROPH DX UP T|Humana Medicare Advantage|HUMANA MA|477.25||||477.25||| 96365|EAP|0940|IV INFUSION 1ST HOUR THER|Blue Cross PPO Specialty|BCBSTX PPO|||||589.50||| 96365|EAP|0450|IV INF THER PROPH DX UP T|Cigna|CIGNA|||||477.25||| 96365|EAP|0260|IV INFUSION 1ST HR THERAP|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||589.50||| 96365|EAP|0450|IV INF THER PROPH DX UP T|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|477.25||||477.25||| 96365|EAP|0450|IV INF THER PROPH DX UP T|Aenta Medicare Advantage|AETNA MEDICARE MA|477.25||||477.25||| 96365|EAP|0260|IV INFUSION 1ST HR THERAP|Blue Cross PPO Specialty|BCBSTX PPO|||||589.50||| 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|477.25||||477.25||| 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 OTHER|477.25||||477.25||| 96365|EAP|0450|IV INF THER PROPH DX UP T|Aetna|AETNA PPO|477.25||||||| 96365|EAP|0450|IV INF THER PROPH DX UP T|Tricare|TRICARE EAST REGION|||||477.25||| 96365|EAP|0450|IV INF THER PROPH DX UP T|NON CONTRACTED|COMMERCIAL OTHER 1|||||477.25||| 96365|EAP|0450|IV INF THER PROPH DX UP T|Blue Cross PPO Specialty|BCBSTX PPO|477.25||||477.25||| 96365|EAP|0450|IV INF THER PROPH DX UP T|Rusk State Hospital|RUSK STATE HOSP|477.25||||477.25||| 96365|EAP|0450|IV INF THER PROPH DX UP T|Medicare|MEDICARE ACUTE|477.25||||477.25||| 96365|EAP|0450|IV INF THER PROPH DX UP T|UTMB|UTMB CORRECTIONAL MANAGED CARE|477.25||||477.25||| 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|Medicaid|MOLINA HEALTHCARE OF TEXAS|477.25||||||| 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|477.25||||477.25||| 96365|EAP|0450|IV INF THER PROPH DX UP T|Medicaid|MEDICAID TEXAS CHILDRENS|||||477.25||| 96365|EAP|0450|IV INF THER PROPH DX UP T|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|477.25||||477.25||| 96365|EAP|0450|IV INF THER PROPH DX UP T|Managed Medicare|HEALTHSPRING MA|477.25||||||| 96365|EAP|0260|IV INFUSION 1ST HR THERAP|Medicaid|MEDICAID|||||589.50||| 96365|EAP|0450|IV INF THER PROPH DX UP T|Managed Medicaid|MEDICAID UNITED HEALTHCARE|477.25||||477.25||| 96365|EAP|0450|IV INF THER PROPH DX UP T|Managed Medicaid|MEDICAID SUPERIOR|477.25||||477.25||| 96365|EAP|0450|IV INF THER PROPH DX UP T|Managed Medicaid|MEDICAID AMERIGROUP|477.25||||477.25||| 96365|EAP|0940|IV INFUSION 1ST HOUR THER|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||589.50||| 96365|EAP|0260|IV INFUSION 1ST HR THERAP|Managed Medicaid|MEDICAID AMERIGROUP|||||589.50||| 96365|EAP|0260|IV INFUSION 1ST HR THERAP|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||589.50||| 96365|EAP|0260|IV INFUSION 1ST HR THERAP|Managed Medicaid|MEDICAID SUPERIOR|||||589.50||| 96365|EAP|0260|IV INFUSION 1ST HR THERAP|Medicare|MEDICARE ACUTE|||||589.50||| 96365|EAP|0450|IV INF THER PROPH DX UP T|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|477.25||||477.25||| 96366|EAP|0260|IV INF THER PROPH DX EA A|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||259.25||| 96366|EAP|0260|IV INF THER PROPH DX EA A|Managed Medicaid|MEDICAID SUPERIOR|259.25||||259.25||| 96366|EAP|0260|IV INF THER PROPH DX EA A|Medicare|MEDICARE ACUTE|259.25||||259.25||| 96366|EAP|0260|IV INF THER PROPH DX EA A|UTMB|UTMB CORRECTIONAL MANAGED CARE|259.25||||259.25||| 96366|EAP|0260|IV INF THER PROPH DX EA A|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||259.25||| 96366|EAP|0260|IV INF THER PROPH DX EA A|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||259.25||| 96366|EAP|0260|IV INF THER PROPH DX EA A|Blue Cross HMO Specialty|BCBSTX HMO|||||259.25||| 96366|EAP|0260|IV INFUSE EA HR UP TO 8|Blue Cross HMO Specialty|BCBSTX HMO|||||2.08||| 96366|EAP|0260|IV INFUSE EA HR UP TO 8|Blue Cross PPO Specialty|BCBSTX PPO|259.25||||2.08||| 96366|EAP|0260|IV INF THER PROPH DX EA A|Blue Cross PPO Specialty|BCBSTX PPO|259.25||||259.25||| 96366|EAP|0260|IV INF THER PROPH DX EA A|Humana Medicare Advantage|HUMANA MA|259.25||||259.25||| 96366|EAP|0260|IV INFUSE EA HR UP TO 8|Humana Medicare Advantage|HUMANA MA|259.25||||2.08||| 96366|EAP|0260|IV INFUSE EA HR UP TO 8|Medicare|MEDICARE ACUTE|259.25||||2.08||| 96366|EAP|0260|IV INF THER PROPH DX EA A|Cigna|CIGNA|||||259.25||| 96366|EAP|0940|IV INF @HR UP TO 8|Blue Cross PPO Specialty|BCBSTX PPO|||||349.25||| 96366|EAP|0260|IV INF THER PROPH DX EA A|United Medicare Advantage|AARP UHC WEST COMPLETE MA|259.25||||259.25||| 96366|EAP|0260|IV INF THER PROPH DX EA A|Aenta Medicare Advantage|AETNA MEDICARE MA|259.25||||||| 96366|EAP|0260|IV INFUSE EA HR UP TO 8|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.08||| 96366|EAP|0940|IV INF @HR UP TO 8|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||349.25||| 96366|EAP|0260|IV INF THER PROPH DX EA A|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||259.25||| 96366|EAP|0260|IV INF THER PROPH DX EA A|Workers Compensation|WORKERS COMPENSATION OTHER|||||259.25||| 96366|EAP|0260|IV INFUSE EA HR UP TO 8|Medicaid|MEDICAID|259.25||||2.08||| 96366|EAP|0260|IV INF THER PROPH DX EA A|Medicaid|MEDICAID TEXAS CHILDRENS|||||259.25||| 96366|EAP|0260|IV INFUSE EA HR UP TO 8|Managed Medicaid|MEDICAID SUPERIOR|259.25||||105.04||| 96366|EAP|0260|IV INFUSE EA HR UP TO 8|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||2.08||| 96367|EAP|0260|IV INF TX DX ADDL SEQ UP|United Medicare Advantage|UHC MEDICARE GOLD MA|231.25||||||| 96367|EAP|0260|IV INF TX DX ADDL SEQ UP|Blue Cross HMO Specialty|BCBSTX HMO|||||231.25||| 96367|EAP|0260|IV INF TX DX ADDL SEQ UP|Medicare|MEDICARE ACUTE|231.25||||231.25||| 96367|EAP|0260|IV INF TX DX ADDL SEQ UP|Rusk State Hospital|RUSK STATE HOSP|231.25||||||| 96367|EAP|0260|IV INF TX DX ADDL SEQ UP|UTMB|UTMB CORRECTIONAL MANAGED CARE|231.25||||231.25||| 96367|EAP|0260|IV INF TX DX ADDL SEQ UP|Managed Medicaid|MEDICAID SUPERIOR|231.25||||231.25||| 96367|EAP|0260|IV INF TX DX ADDL SEQ UP|Managed Medicaid|MEDICAID AMERIGROUP|||||231.25||| 96367|EAP|0260|IV INF TX DX ADDL SEQ UP|Medicaid|MEDICAID|231.25||||||| 96367|EAP|0260|IV INF TX DX ADDL SEQ UP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||231.25||| 96367|EAP|0260|IV INF TX DX ADDL SEQ UP|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|231.25||||||| 96367|EAP|0260|IV INF TX DX ADDL SEQ UP|Blue Cross PPO Specialty|BCBSTX PPO|||||231.25||| 96367|EAP|0260|IV INF TX DX ADDL SEQ UP|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|231.25||||||| 96367|EAP|0260|IV INF TX DX ADDL SEQ UP|Humana Medicare Advantage|HUMANA MA|231.25||||231.25||| 96367|EAP|0260|IV INF TX DX ADDL SEQ UP|Workers Compensation|WORKERS COMPENSATION OTHER|||||231.25||| 96367|EAP|0260|IV INF TX DX ADDL SEQ UP|United Medicare Advantage|AARP UHC WEST COMPLETE MA|231.25||||231.25||| 96367|EAP|0260|IV INF TX DX ADDL SEQ UP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||231.25||| 96368|EAP|0260|IV INF TX DX CONCURRENT|Medicare|MEDICARE ACUTE|129.25||||129.25||| 96368|EAP|0260|IV INF TX DX CONCURRENT|UTMB|UTMB CORRECTIONAL MANAGED CARE|129.25||||||| 96368|EAP|0260|IV INF TX DX CONCURRENT|Blue Cross HMO Specialty|BCBSTX HMO|||||129.25||| 96368|EAP|0260|IV INF TX DX CONCURRENT|Blue Cross PPO Specialty|BCBSTX PPO|129.25||||129.25||| 96368|EAP|0260|INTRAVENOUS INFUSION CONC|Blue Cross PPO Specialty|BCBSTX PPO|129.25||||129.25||| 96368|EAP|0260|IV INF TX DX CONCURRENT|Humana Medicare Advantage|HUMANA MA|129.25||||||| 96368|EAP|0260|IV INF TX DX CONCURRENT|Cigna|CIGNA|||||129.25||| 96372|EAP|0940|INJ ADM THERAPEUTIC|United Healthcare|UNITED HEALTHCARE OTHER|||||291.25||| 96372|EAP|0260|INJ SUBQ/IM|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||329.50||| 96372|EAP|0260|INJ SUBQ/IM|Workers Compensation|UT EMPLOYEE INJURY|||||329.50||| 96372|EAP|0260|INJ SUBQ/IM|United Healthcare|UNITED HEALTHCARE OTHER|||||329.50||| 96372|EAP|0260|INJ SUBQ/IM|United Medicare Advantage|UHC MEDICARE GOLD MA|329.50||||329.50||| 96372|EAP|0260|INJ SUBQ/IM|United Healthcare|UNITED HEALTHCARE|329.50||||329.50||| 96372|EAP|0260|INJ SUBQ/IM|United Healthcare|UMR UNITED MEDICAL RESOURCES|329.50||||329.50||| 96372|EAP|0260|INJ SUBQ/IM|United Healthcare|TML GROUP BENEFITS|329.50||||||| 96372|EAP|0940|INJ ANTIBIOTIC|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||353.50||| 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|||||291.25||| 96372|EAP|0260|INJ SUBQ/IM|Veterans Affairs|VETERANS ADMINISTRATION|329.50||||329.50||| 96372|EAP|0940|INJ ADM THERAPEUTIC|Veterans Affairs|VETERANS ADMINISTRATION|||||291.25||| 96372|EAP|0260|INJ SUBQ/IM|Workers Compensation|WORKERS COMPENSATION OTHER|329.50||||329.50||| 96372|EAP|0260|INJ SUBQ/IM|Humana Medicare Advantage|HUMANA MA|329.50||||329.50||| 96372|EAP|0940|INJ ADM THERAPEUTIC|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|291.25||||||| 96372|EAP|0260|INJ SUBQ/IM|Cigna|CIGNA|||||329.50||| 96372|EAP|0940|INJ ADM THERAPEUTIC|Humana Medicare Advantage|HUMANA MA|||||291.25||| 96372|EAP|0940|INJ ADM THERAPEUTIC|Blue Cross PPO Specialty|BCBSTX PPO|||||291.25||| 96372|EAP|0260|INJ SUBQ/IM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||329.50||| 96372|EAP|0260|INJ SUBQ/IM|Aenta Medicare Advantage|AETNA MEDICARE MA|329.50||||329.50||| 96372|EAP|0260|INJ SUBQ/IM|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|329.50||||329.50||| 96372|EAP|0260|INJ SUBQ/IM|Access Direct Platinum|HEALTHFIRST TPA UMR|||||329.50||| 96372|EAP|0940|INJ ADM THERAPEUTIC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||291.25||| 96372|EAP|0940|INJ ADM THERAPEUTIC|Aenta Medicare Advantage|AETNA MEDICARE MA|||||291.25||| 96372|EAP|0260|INJ SUBQ/IM|Aetna|AETNA OTHER|||||329.50||| 96372|EAP|0260|INJ SUBQ/IM|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||329.50||| 96372|EAP|0260|INJ SUBQ/IM|Blue Cross HMO Specialty|BCBSTX HMO|329.50||||329.50||| 96372|EAP|0260|INJ SUBQ/IM|Aetna|AETNA PPO|329.50||||329.50||| 96372|EAP|0940|INJ ANTIBIOTIC|Blue Cross HMO Specialty|BCBSTX HMO|||||353.50||| 96372|EAP|0940|INJ ADM THERAPEUTIC|Blue Cross HMO Specialty|BCBSTX HMO|||||291.25||| 96372|EAP|0940|INJ ADM THERAPEUTIC|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||291.25||| 96372|EAP|0260|INJ SUBQ/IM|Blue Cross PPO Specialty|BCBSTX PPO|329.50||||329.50||| 96372|EAP|0260|INJ SUBQ/IM|Blue Cross PPO Specialty|BCBSTX OTHER|||||329.50||| 96372|EAP|0260|INJ SUBQ/IM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|329.50||||329.50||| 96372|EAP|0260|INJ SUBQ/IM|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||329.50||| 96372|EAP|0260|INJ SUBQ/IM|Managed Medicaid|MEDICAID SUPERIOR|329.50||||329.50||| 96372|EAP|0260|INJ SUBQ/IM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|329.50||||329.50||| 96372|EAP|0260|INJ SUBQ/IM|Managed Medicare|HEALTHSPRING MA|||||329.50||| 96372|EAP|0940|INJ ADM THERAPEUTIC|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||291.25||| 96372|EAP|0260|INJ SUBQ/IM|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||329.50||| 96372|EAP|0260|INJ SUBQ/IM|Medicaid|MEDICAID TEXAS CHILDRENS|||||329.50||| 96372|EAP|0260|INJ SUBQ/IM|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||329.50||| 96372|EAP|0260|INJ SUBQ/IM|Medicaid|MEDICAID HMO|||||329.50||| 96372|EAP|0260|INJ SUBQ/IM|Medicaid|MEDICAID|||||329.50||| 96372|EAP|0260|INJ SUBQ/IM|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|329.50||||329.50||| 96372|EAP|0260|INJ SUBQ/IM|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||329.50||| 96372|EAP|0940|INJ ADM THERAPEUTIC|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||291.25||| 96372|EAP|0940|INJ ANTIBIOTIC|Managed Medicaid|MEDICAID AMERIGROUP|||||353.50||| 96372|EAP|0940|INJ ADM THERAPEUTIC|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||291.25||| 96372|EAP|0260|INJ SUBQ/IM|Managed Medicaid|MEDICAID AMERIGROUP|329.50||||329.50||| 96372|EAP|0940|INJ ADM THERAPEUTIC|Managed Medicaid|MEDICAID SUPERIOR|291.25||||291.25||| 96372|EAP|0940|INJ ADM THERAPEUTIC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||291.25||| 96372|EAP|0940|INJ ADM THERAPEUTIC|United Healthcare|UNITED HEALTHCARE|||||291.25||| 96372|EAP|0260|INJ SUBQ/IM|United Healthcare|UNITED HEALTHCARE|||||329.50||| 96372|EAP|0260|INJ SUBQ/IM|United Medicare Advantage|AARP UHC WEST COMPLETE MA|329.50||||329.50||| 96372|EAP|0260|INJ SUBQ/IM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|329.50||||329.50||| 96372|EAP|0940|INJ ADM ANTIBIOTIC|Managed Medicaid|MEDICAID SUPERIOR|291.25||||304.25||| 96372|EAP|0260|INJ SUBQ/IM|NON CONTRACTED|COMMERCIAL OTHER 2|||||329.50||| 96372|EAP|0260|INJ SUBQ/IM|NON CONTRACTED|COMMERCIAL OTHER 1|329.50||||329.50||| 96372|EAP|0260|INJ SUBQ/IM|Medicare|MEDICARE ACUTE|329.50||||329.50||| 96372|EAP|0940|INJ ADM THERAPEUTIC|NON CONTRACTED|COMMERCIAL OTHER 2|291.25||||||| 96372|EAP|0260|INJ SUBQ/IM|Rusk State Hospital|RUSK STATE HOSP|329.50||||329.50||| 96372|EAP|0940|INJ ADM THERAPEUTIC|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||291.25||| 96372|EAP|0260|INJ SUBQ/IM|Managed Medicaid|MEDICAID UNITED HEALTHCARE|329.50||||329.50||| 96372|EAP|0940|INJ ADM THERAPEUTIC|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||291.25||| 96372|EAP|0260|INJ SUBQ/IM|Tricare|TRICARE EAST REGION|||||329.50||| 96372|EAP|0940|INJ ADM THERAPEUTIC|Managed Medicaid|MEDICAID AMERIGROUP|||||291.25||| 96372|EAP|0260|INJ SUBQ/IM|UTMB|UTMB CORRECTIONAL MANAGED CARE|329.50||||329.50||| 96372|EAP|0940|INJ ANTIBIOTIC|Medicare|MEDICARE ACUTE|||||353.50||| 96372|EAP|0940|INJ ADM THERAPEUTIC|Medicare|MEDICARE ACUTE|||||291.25||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|NON CONTRACTED|COMMERCIAL OTHER 1|3.28||||3.28||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|Medicare|MEDICARE PART B ONLY IP|3.28||||||| 96374|EAP|0940|IV PUSH|NON CONTRACTED|COMMERCIAL OTHER 2|||||387.25||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|Rusk State Hospital|RUSK STATE HOSP|3.28||||3.28||| 96374|EAP|0940|IV PUSH|Medicaid|MEDICAID|||||387.25||| 96374|EAP|0940|IV PUSH|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||387.25||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||3.28||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|Tricare|TRICARE EAST REGION|||||3.28||| 96374|EAP|0940|IV PUSH|Tricare|TRICARE EAST REGION|||||387.25||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.28||||3.28||| 96374|EAP|0940|IV PUSH|UTMB|UTMB CORRECTIONAL MANAGED CARE|387.25||||||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|Managed Medicaid|MEDICAID UNITED HEALTHCARE|3.28||||3.28||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|Managed Medicaid|MEDICAID SUPERIOR|3.28||||3.28||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.28||||3.28||| 96374|EAP|0260|INJ ADM IV PUSH|Managed Medicaid|MEDICAID SUPERIOR|304.25||||304.25||| 96374|EAP|0260|INJ ADM IV PUSH|Managed Medicaid|MEDICAID AMERIGROUP|3.28||||304.25||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|3.28||||3.28||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|Managed Medicare|HEALTHSPRING MA|3.28||||3.28||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|Managed Medicare|BCBS MEDICARE PPO MA|||||3.28||| 96374|EAP|0940|IV PUSH|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||387.25||| 96374|EAP|0940|IV PUSH|Managed Medicare|HEALTHSPRING MA|||||387.25||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|Medicaid|COUNTY INDIGENT HEALTH OTHER|3.28||||3.28||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||3.28||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|Medicaid|MEDICAID HMO|||||3.28||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|Medicaid|MEDICAID TEXAS CHILDRENS|||||3.28||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|Medicaid|SUPERIOR HEALTHPLAN CHIP|3.28||||3.28||| 96374|EAP|0940|IV PUSH|Managed Medicaid|MEDICAID SUPERIOR|||||387.25||| 96374|EAP|0940|IV PUSH|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||387.25||| 96374|EAP|0940|IV PUSH|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||387.25||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.28||||3.28||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|Medicaid|MEDICAID|3.28||||3.28||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|Aenta Medicare Advantage|AETNA MEDICARE MA|3.28||||3.28||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.28||||3.28||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|3.28||||3.28||| 96374|EAP|0940|IV PUSH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||387.25||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|Medicaid|MEDICAID PCCM|||||3.28||| 96374|EAP|0940|IV PUSH|Aenta Medicare Advantage|AETNA MEDICARE MA|||||387.25||| 96374|EAP|0260|INJ ADM IV PUSH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.28||||304.25||| 96374|EAP|0940|IV PUSH|Managed Medicaid|MEDICAID AMERIGROUP|||||387.25||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|Blue Cross HMO Specialty|BCBSTX HMO|3.28||||3.28||| 96374|EAP|0260|INJ ADM IV PUSH|Blue Cross HMO Specialty|BCBSTX HMO|3.28||||304.25||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|Blue Cross PPO Specialty|BCBSTX OTHER|3.28||||3.28||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|Aetna|AETNA PPO|3.28||||3.28||| 96374|EAP|0260|INJ ADM IV PUSH|Medicaid|MEDICAID|3.28||||304.25||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|Aetna|AETNA OTHER|||||3.28||| 96374|EAP|0940|IV PUSH|Blue Cross HMO Specialty|BCBSTX HMO|||||387.25||| 96374|EAP|0940|IV PUSH|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||387.25||| 96374|EAP|0940|IV PUSH|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||387.25||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|Blue Cross PPO Specialty|BCBSTX PPO|3.28||||3.28||| 96374|EAP|0260|INJ ADM IV PUSH|Blue Cross PPO Specialty|BCBSTX PPO|3.28||||304.25||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|Humana Medicare Advantage|HUMANA MA|3.28||||3.28||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|Cigna|CIGNA|3.28||||||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|Managed Medicare|HOSPICE OF EAST TEXAS|3.28||||||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|Cigna|CIGNA|3.28||||3.28||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|Cigna|CIGNA|||||3.28||| 96374|EAP|0940|IV PUSH|Humana Medicare Advantage|HUMANA MA|387.25||||387.25||| 96374|EAP|0940|IV PUSH|Blue Cross PPO Specialty|BCBSTX PPO|||||387.25||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|Managed Medicaid|MEDICAID AMERIGROUP|3.28||||3.28||| 96374|EAP|0940|IV PUSH|Blue Cross PPO Specialty|BCBSTX OTHER|||||387.25||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|3.28||||3.28||| 96374|EAP|0940|IV PUSH|Medicare|MEDICARE ACUTE|387.25||||387.25||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|304.25||||3.28||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|United Medicare Advantage|AARP UHC WEST COMPLETE MA|3.28||||3.28||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||3.28||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|United Medicare Advantage|UHC MEDICARE GOLD MA|3.28||||3.28||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.28||||3.28||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|United Healthcare|UNITED HEALTHCARE|3.28||||3.28||| 96374|EAP|0940|IV PUSH|Medicaid|MEDICAID HMO|||||387.25||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|United Healthcare|UMR UNITED MEDICAL RESOURCES|3.28||||3.28||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|United Healthcare|TML GROUP BENEFITS|3.28||||3.28||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|United Healthcare|GEHA|||||3.28||| 96374|EAP|0260|INJ ADM IV PUSH|United Healthcare|UNITED HEALTHCARE OTHER|||||304.25||| 96374|EAP|0260|INJ ADM IV PUSH|United Healthcare|UNITED HEALTHCARE|3.28||||304.25||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|United Healthcare|UNITED HEALTHCARE OTHER|||||3.28||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|3.28||||3.28||| 96374|EAP|0940|IV PUSH|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||387.25||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|Medicare|MEDICARE ACUTE|3.28||||3.28||| 96374|EAP|0940|IV PUSH|United Medicare Advantage|UHC MEDICARE GOLD MA|||||387.25||| 96374|EAP|0940|IV PUSH|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||387.25||| 96374|EAP|0940|IV PUSH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||387.25||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|Veterans Affairs|VETERANS ADMINISTRATION|3.28||||3.28||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|Workers Compensation|WORKERS COMPENSATION OTHER|3.28||||3.28||| 96374|EAP|0260|INJ IV PUSH INITIAL DRUG|Workers Compensation|UT EMPLOYEE INJURY|3.28||||||| 96374|EAP|0940|IV PUSH|Workers Compensation|WORKERS COMPENSATION OTHER|||||387.25||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|233.75||||233.75||| 96375|EAP|0260|IV PUSH @ ADDITIONAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|233.75||||317.25||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|United Medicare Advantage|UHC MEDICARE GOLD MA|233.75||||233.75||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|United Medicare Advantage|AARP UHC WEST COMPLETE MA|233.75||||233.75||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|United Healthcare|UNITED HEALTHCARE OTHER|||||233.75||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|United Healthcare|UNITED HEALTHCARE|233.75||||233.75||| 96375|EAP|0260|IV PUSH @ ADDITIONAL|United Healthcare|UMR UNITED MEDICAL RESOURCES|233.75||||317.25||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Veterans Affairs|VETERANS ADMINISTRATION|233.75||||233.75||| 96375|EAP|0260|IV PUSH @ ADDITIONAL|Workers Compensation|WORKERS COMPENSATION OTHER|233.75||||317.25||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Humana Medicare Advantage|HUMANA MA|233.75||||233.75||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Cigna|CIGNA|||||233.75||| 96375|EAP|0260|IV PUSH @ ADDITIONAL|Cigna|CIGNA|||||317.25||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Cigna|CIGNA|233.75||||233.75||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Cigna|CIGNA|233.75||||||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|233.75||||233.75||| 96375|EAP|0260|IV PUSH @ ADDITIONAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|233.75||||317.25||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|233.75||||233.75||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|233.75||||233.75||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Blue Cross HMO Specialty|BCBSTX HMO|233.75||||233.75||| 96375|EAP|0260|IV PUSH @ ADDITIONAL|Blue Cross HMO Specialty|BCBSTX HMO|233.75||||317.25||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Aetna|AETNA PPO|233.75||||233.75||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Aetna|AETNA OTHER|||||233.75||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Blue Cross PPO Specialty|BCBSTX OTHER|233.75||||233.75||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Aenta Medicare Advantage|AETNA MEDICARE MA|233.75||||233.75||| 96375|EAP|0260|IV PUSH @ ADDITIONAL|Blue Cross PPO Specialty|BCBSTX PPO|233.75||||317.25||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Blue Cross PPO Specialty|BCBSTX PPO|233.75||||233.75||| 96375|EAP|0260|IV PUSH @ ADDITIONAL|Managed Medicaid|MEDICAID UNITED HEALTHCARE|233.75||||317.25||| 96375|EAP|0260|IV PUSH @ ADDITIONAL|Managed Medicaid|MEDICAID SUPERIOR|233.75||||317.25||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|233.75||||||| 96375|EAP|0260|IV PUSH @ ADDITIONAL|Managed Medicaid|MEDICAID AMERIGROUP|233.75||||317.25||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Workers Compensation|WORKERS COMPENSATION OTHER|233.75||||233.75||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Managed Medicaid|MEDICAID UNITED HEALTHCARE|233.75||||233.75||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Managed Medicaid|MEDICAID SUPERIOR|233.75||||233.75||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|233.75||||233.75||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Managed Medicaid|MEDICAID AMERIGROUP|233.75||||233.75||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Managed Medicare|HEALTHSPRING MA|233.75||||233.75||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||233.75||| 96375|EAP|0260|IV PUSH @ ADDITIONAL|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|233.75||||317.25||| 96375|EAP|0260|IV PUSH @ ADDITIONAL|Humana Medicare Advantage|HUMANA MA|317.25||||317.25||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Medicaid|COUNTY INDIGENT HEALTH OTHER|233.75||||233.75||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Medicaid|MEDICAID HMO|||||233.75||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Medicaid|MEDICAID TEXAS CHILDRENS|||||233.75||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|United Healthcare|UMR UNITED MEDICAL RESOURCES|233.75||||233.75||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Medicaid|MOLINA HEALTHCARE OF TEXAS|233.75||||233.75||| 96375|EAP|0260|IV PUSH @ ADDITIONAL|NON CONTRACTED|COMMERCIAL OTHER 1|233.75||||317.25||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|NON CONTRACTED|COMMERCIAL OTHER 1|233.75||||233.75||| 96375|EAP|0260|IV PUSH @ ADDITIONAL|Medicare|MEDICARE ACUTE|233.75||||317.25||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Medicare|MEDICARE PART B ONLY IP|233.75||||||| 96375|EAP|0260|IV PUSH @ ADDITIONAL|NON CONTRACTED|COMMERCIAL OTHER 2|||||317.25||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Medicare|MEDICARE ACUTE|233.75||||233.75||| 96375|EAP|0260|IV PUSH @ ADDITIONAL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|233.75||||317.25||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Rusk State Hospital|RUSK STATE HOSP|233.75||||233.75||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Tricare|TRICARE EAST REGION|||||233.75||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||233.75||| 96375|EAP|0260|IV PUSH @ ADDITIONAL|Medicaid|MEDICAID|233.75||||317.25||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|UTMB|UTMB CORRECTIONAL MANAGED CARE|233.75||||233.75||| 96375|EAP|0260|IV PUSH @ ADDITIONAL|Medicaid|MEDICAID HMO|||||317.25||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Managed Medicare|HOSPICE OF EAST TEXAS|233.75||||||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|233.75||||233.75||| 96375|EAP|0260|INJ IV PUSH ADDL SEQ NEW|Medicaid|MEDICAID|233.75||||233.75||| 96376|EAP|0260|IV PUSH EA ADD SEQ SAME D|NON CONTRACTED|COMMERCIAL OTHER 1|||||207.75||| 96376|EAP|0260|IV PUSH EA ADD SEQ SAME D|NON CONTRACTED|COMMERCIAL OTHER 1|||||201.75||| 96376|EAP|0260|IV PUSH EA ADD SEQ SAME D|Medicare|MEDICARE ACUTE|207.75||||201.75||| 96376|EAP|0260|IV PUSH EA ADD SEQ SAME D|Medicare|MEDICARE ACUTE|207.75||||207.75||| 96376|EAP|0260|IV PUSH EA ADD SEQ SAME D|Rusk State Hospital|RUSK STATE HOSP|207.75||||207.75||| 96376|EAP|0260|IV PUSH EA ADD SEQ SAME D|Tricare|TRICARE EAST REGION|||||207.75||| 96376|EAP|0260|IV PUSH EA ADD SEQ SAME D|UTMB|UTMB CORRECTIONAL MANAGED CARE|207.75||||207.75||| 96376|EAP|0260|IV PUSH EA ADD SEQ SAME D|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||201.75||| 96376|EAP|0260|IV PUSH EA ADD SEQ SAME D|Managed Medicaid|MEDICAID SUPERIOR|207.75||||207.75||| 96376|EAP|0260|IV PUSH EA ADD SEQ SAME D|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|207.75||||207.75||| 96376|EAP|0260|IV PUSH EA ADD SEQ SAME D|Managed Medicaid|MEDICAID AMERIGROUP|207.75||||207.75||| 96376|EAP|0260|IV PUSH EA ADD SEQ SAME D|UTMB|UTMB CORRECTIONAL MANAGED CARE|207.75||||201.75||| 96376|EAP|0260|IV PUSH EA ADD SEQ SAME D|Managed Medicaid|MEDICAID AMERIGROUP|207.75||||201.75||| 96376|EAP|0260|IV PUSH EA ADD SEQ SAME D|Medicaid|MEDICAID|||||201.75||| 96376|EAP|0940|IV PUSH @ADD SEQ SAME DRU|Managed Medicaid|MEDICAID SUPERIOR|201.75||||201.75||| 96376|EAP|0940|IV PUSH @ADD SEQ SAME DRU|Managed Medicaid|MEDICAID AMERIGROUP|||||201.75||| 96376|EAP|0260|IV PUSH EA ADD SEQ SAME D|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||207.75||| 96376|EAP|0260|IV PUSH EA ADD SEQ SAME D|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||201.75||| 96376|EAP|0260|IV PUSH EA ADD SEQ SAME D|Aenta Medicare Advantage|AETNA MEDICARE MA|207.75||||||| 96376|EAP|0260|IV PUSH EA ADD SEQ SAME D|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|207.75||||||| 96376|EAP|0260|IV PUSH EA ADD SEQ SAME D|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||201.75||| 96376|EAP|0260|IV PUSH EA ADD SEQ SAME D|Blue Cross HMO Specialty|BCBSTX HMO|207.75||||207.75||| 96376|EAP|0260|IV PUSH EA ADD SEQ SAME D|Aetna|AETNA PPO|207.75||||||| 96376|EAP|0260|IV PUSH EA ADD SEQ SAME D|Blue Cross PPO Specialty|BCBSTX PPO|207.75||||207.75||| 96376|EAP|0260|IV PUSH EA ADD SEQ SAME D|Blue Cross PPO Specialty|BCBSTX PPO|207.75||||201.75||| 96376|EAP|0260|IV PUSH EA ADD SEQ SAME D|Managed Medicaid|MEDICAID SUPERIOR|207.75||||201.75||| 96376|EAP|0260|IV PUSH EA ADD SEQ SAME D|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||207.75||| 96376|EAP|0260|IV PUSH EA ADD SEQ SAME D|Humana Medicare Advantage|HUMANA MA|207.75||||207.75||| 96376|EAP|0260|IV PUSH EA ADD SEQ SAME D|Humana Medicare Advantage|HUMANA MA|201.75||||201.75||| 96376|EAP|0260|IV PUSH EA ADD SEQ SAME D|Cigna|CIGNA|||||207.75||| 96376|EAP|0260|IV PUSH EA ADD SEQ SAME D|Cigna|CIGNA|||||201.75||| 96376|EAP|0260|IV PUSH EA ADD SEQ SAME D|United Medicare Advantage|UHC MEDICARE GOLD MA|||||207.75||| 96376|EAP|0260|IV PUSH EA ADD SEQ SAME D|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||207.75||| 96376|EAP|0260|IV PUSH EA ADD SEQ SAME D|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||207.75||| 96376|EAP|0260|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|Blue Cross PPO Specialty|BCBSTX PPO|||||201.75||| 96376|EAP|0260|IV PUSH EA ADD SEQ SAME D|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|207.75||||201.75||| 96376|EAP|0260|IV PUSH EA ADD SEQ SAME D|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|207.75||||207.75||| 96376|EAP|0260|IV PUSH EA ADD SEQ SAME D|United Healthcare|UNITED HEALTHCARE|207.75||||||| 96376|EAP|0260|IV PUSH EA ADD SEQ SAME D|United Healthcare|UNITED HEALTHCARE|||||207.75||| 96376|EAP|0260|IV PUSH EA ADD SEQ SAME D|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||201.75||| 96376|EAP|0260|IV PUSH EA ADD SEQ SAME D|Veterans Affairs|VETERANS ADMINISTRATION|||||207.75||| 96376|EAP|0260|IV PUSH EA ADD SEQ SAME D|Veterans Affairs|VETERANS ADMINISTRATION|||||201.75||| 96376|EAP|0260|IV PUSH EA ADD SEQ SAME D|Workers Compensation|WORKERS COMPENSATION OTHER|207.75||||207.75||| 96376|EAP|0260|IV PUSH EA ADD SEQ SAME D|Workers Compensation|WORKERS COMPENSATION OTHER|207.75||||201.75||| 96376|EAP|0260|IV PUSH EA ADD SEQ SAME D|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|207.75||||||| 96413|EAP|0335|CHEMO INFUSE UP TO 1 HOUR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||740.50||| 96413|EAP|0335|CHEMO INFUSE UP TO 1 HOUR|Blue Cross PPO Specialty|BCBSTX PPO|||||740.50||| 96413|EAP|0335|CHEMO INFUSE UP TO 1 HOUR|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||740.50||| 96413|EAP|0335|CHEMO INFUSE UP TO 1 HOUR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||740.50||| 96413|EAP|0335|CHEMO INFUSE UP TO 1 HOUR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||740.50||| 96413|EAP|0335|CHEMO INFUSE UP TO 1 HOUR|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||740.50||| 96413|EAP|0335|CHEMO INFUSE UP TO 1 HOUR|Access Direct Platinum|HEALTHFIRST TPA UMR|||||740.50||| 96413|EAP|0335|CHEMO INFUSE UP TO 1 HOUR|Blue Cross HMO Specialty|BCBSTX HMO|||||740.50||| 96413|EAP|0335|CHEMO INFUSE UP TO 1 HOUR|Tricare|TRICARE EAST REGION|||||740.50||| 96413|EAP|0335|CHEMO INFUSE UP TO 1 HOUR|Medicare|MEDICARE ACUTE|||||740.50||| 96415|EAP|0335|CHEMO INFUSE EA + HR UP T|Medicare|MEDICARE ACUTE|||||2.08||| 96415|EAP|0335|CHEMO INFUSE EA + HR UP T|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||2.08||| 96415|EAP|0335|CHEMO INFUSE EA + HR UP T|Blue Cross HMO Specialty|BCBSTX HMO|||||2.08||| 96415|EAP|0335|CHEMO INFUSE EA + HR UP T|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2.08||| 96415|EAP|0335|CHEMO INFUSE EA + HR UP T|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2.08||| 96415|EAP|0335|CHEMO INFUSE EA + HR UP T|Blue Cross PPO Specialty|BCBSTX PPO|||||2.08||| 96415|EAP|0335|CHEMO INFUSE EA + HR UP T|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||2.08||| 96415|EAP|0335|CHEMO INFUSE EA + HR UP T|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||2.08||| 96415|EAP|0335|CHEMO INFUSE EA + HR UP T|Access Direct Platinum|HEALTHFIRST TPA UMR|||||2.08||| 96523|EAP|0361|IRRIGATION OF VAD (PORT F|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||182.25||| 96523|EAP|0361|IRRIGATION OF VAD (PORT F|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||182.25||| 96523|EAP|0361|IRRIGATION OF VAD (PORT F|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||182.25||| 96900|EAP|0940|BILIRUBIN LIGHT 24HRS|Medicaid|MEDICAID|613.75||||||| 96900|EAP|0940|BILIRUBIN LIGHT 24HRS|Managed Medicaid|MEDICAID SUPERIOR|613.75||||613.75||| 96900|EAP|0940|BILIRUBIN LIGHT 24HRS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|613.75||||||| 97|DRG||NON-BACTERIAL INFECT OF NERVOUS SYS EXC VIRAL MENINGITIS W MCC|UTMB|UTMB CORRECTIONAL MANAGED CARE|102,178.16|29458.05|29458.05|29458.05|||| 97110|EAP|0420|THERAPEUTIC EX 15M 1-1|Workers Compensation|WORKERS COMPENSATION OTHER|289.75||||289.75||| 97110|EAP|0420|THERAPEUTIC EX 15M 1-1|Workers Compensation|UT EMPLOYEE INJURY|289.75||||||| 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||||||| 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|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|289.75||||||| 97110|EAP|0420|THERAPEUTIC EX 15M 1-1|Aenta Medicare Advantage|AETNA MEDICARE MA|289.75||||||| 97110|EAP|0420|THERAPEUTIC EX 15M 1-1|Blue Cross HMO Specialty|BCBSTX HMO|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|Managed Medicaid|MEDICAID UNITED HEALTHCARE|289.75||||||| 97110|EAP|0420|THERAPEUTIC EX 15M 1-1|Tricare|TRICARE EAST REGION|289.75||||||| 97110|EAP|0420|THERAPEUTIC EX 15M 1-1|Medicaid|MEDICAID|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|NON CONTRACTED|COMMERCIAL OTHER 1|289.75||||||| 97110|EAP|0420|THERAPEUTIC EX 15M 1-1|UTMB|UTMB CORRECTIONAL MANAGED CARE|289.75||||||| 97110|EAP|0420|THERAPEUTIC EX 15M 1-1|Humana Medicare Advantage|HUMANA MA|289.75||||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||||||| 97116|EAP|0420|GAIT TRAINING EA 15M|Tricare|TRICARE EAST REGION|312.50||||||| 97116|EAP|0420|GAIT TRAINING EA 15M|Medicaid|MEDICAID|312.50||||||| 97116|EAP|0420|GAIT TRAINING EA 15M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|312.50||||||| 97116|EAP|0420|GAIT TRAINING EA 15M|Managed Medicaid|MEDICAID SUPERIOR|312.50||||||| 97116|EAP|0420|GAIT TRAINING EA 15M|Medicare|MEDICARE ACUTE|312.50||||312.50||| 97116|EAP|0420|GAIT TRAINING EA 15M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|312.50||||||| 97116|EAP|0420|GAIT TRAINING EA 15M|UTMB|UTMB CORRECTIONAL MANAGED CARE|312.50||||||| 97116|EAP|0420|GAIT TRAINING EA 15M|Blue Cross PPO Specialty|BCBSTX PPO|312.50||||312.50||| 97116|EAP|0420|GAIT TRAINING EA 15M|Blue Cross PPO Specialty|BCBSTX OTHER|312.50||||||| 97116|EAP|0420|GAIT TRAINING EA 15M|Humana Medicare Advantage|HUMANA MA|312.50||||312.50||| 97116|EAP|0420|GAIT TRAINING EA 15M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|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|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|312.50||||||| 97116|EAP|0420|GAIT TRAINING EA 15M|Workers Compensation|WORKERS COMPENSATION OTHER|312.50||||312.50||| 97116|EAP|0420|GAIT TRAINING EA 15M|NON CONTRACTED|COMMERCIAL OTHER 1|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|Workers Compensation|UT EMPLOYEE INJURY|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|Veterans Affairs|VETERANS ADMINISTRATION|312.50||||||| 97116|EAP|0420|GAIT TRAINING EA 15M|United Medicare Advantage|AARP UHC WEST COMPLETE MA|312.50||||312.50||| 97161|EAP|0424|PT EVAL LOW COMPLX 20 MIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|3.33||||||| 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||||||| 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|Workers Compensation|UT EMPLOYEE INJURY|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|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.33||||||| 97161|EAP|0424|PT EVAL LOW COMPLX 20 MIN|Blue Cross HMO Specialty|BCBSTX HMO|3.33||||||| 97161|EAP|0424|PT EVAL LOW COMPLX 20 MIN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|3.33||||||| 97161|EAP|0424|PT EVAL LOW COMPLX 20 MIN|Workers Compensation|WORKERS COMPENSATION OTHER|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|Blue Cross PPO Specialty|BCBSTX OTHER|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|Managed Medicaid|MEDICAID UNITED HEALTHCARE|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|NON CONTRACTED|COMMERCIAL OTHER 1|3.33||||||| 97161|EAP|0424|PT EVAL LOW COMPLX 20 MIN|Tricare|TRICARE EAST REGION|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|UTMB|UTMB CORRECTIONAL MANAGED CARE|3.33||||||| 97166|EAP|0424|EVAL OT 45 MIN|Humana Medicare Advantage|HUMANA MA|3.71||||3.71||| 975|DRG||HIV W MAJOR RELATED CONDITION W CC|UTMB|UTMB CORRECTIONAL MANAGED CARE|33,305.75|13044.26|13044.26|13044.26|||| 97530|EAP|0420|THERAPEUTIC ACT EA 15M1-1|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|231.25||||||| 97530|EAP|0420|THERAPEUTIC ACT EA 15M1-1|United Medicare Advantage|UHC MEDICARE GOLD 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||||231.25||| 97530|EAP|0420|THERAPEUTIC ACT EA 15M1-1|Veterans Affairs|VETERANS ADMINISTRATION|231.25||||||| 97530|EAP|0420|THERAPEUTIC ACT EA 15M1-1|Workers Compensation|WORKERS COMPENSATION OTHER|231.25||||231.25||| 97530|EAP|0420|THERAPEUTIC ACT EA 15M1-1|Workers Compensation|UT EMPLOYEE INJURY|231.25||||||| 97530|EAP|0420|THERAPEUTIC ACT EA 15M1-1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|231.25||||||| 97530|EAP|0420|THERAPEUTIC ACT EA 15M1-1|Humana Medicare Advantage|HUMANA MA|231.25||||231.25||| 97530|EAP|0420|THERAPEUTIC ACT EA 15M1-1|NON CONTRACTED|COMMERCIAL OTHER 1|231.25||||||| 97530|EAP|0420|THERAPEUTIC ACT EA 15M1-1|UTMB|UTMB CORRECTIONAL MANAGED CARE|231.25||||||| 97530|EAP|0420|THERAPEUTIC ACT EA 15M1-1|Medicare|MEDICARE ACUTE|231.25||||231.25||| 97530|EAP|0420|THERAPEUTIC ACT EA 15M1-1|Tricare|TRICARE EAST REGION|231.25||||||| 97530|EAP|0420|THERAPEUTIC ACT EA 15M1-1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|231.25||||||| 97530|EAP|0420|THERAPEUTIC ACT EA 15M1-1|Managed Medicaid|MEDICAID SUPERIOR|231.25||||||| 97530|EAP|0420|THERAPEUTIC ACT EA 15M1-1|Managed Medicaid|MEDICAID UNITED HEALTHCARE|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|Blue Cross PPO Specialty|BCBSTX PPO|231.25||||231.25||| 97530|EAP|0420|THERAPEUTIC ACT EA 15M1-1|Blue Cross HMO Specialty|BCBSTX HMO|231.25||||||| 97597|EAP|0450|DEBRIDE SKIN PARTIAL THIC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||5.56||| 97597|EAP|0450|DEBRIDE SKIN PARTIAL THIC|Workers Compensation|WORKERS COMPENSATION OTHER|||||5.56||| 97602|EAP|0761|DEBRIDEMENT NON SELECTIVE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||175.50||| 97802|EAP|0942|INDV ASMT & INTERV NEW PA|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.61||| 97802|EAP|0942|INDV ASMT & INTERV NEW PA|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.61||| 97802|EAP|0942|INDV ASMT & INTERV NEW PA|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||0.61||| 97802|EAP|0942|INDV ASMT & INTERV NEW PA|Managed Medicaid|MEDICAID AMERIGROUP|||||0.61||| 97802|EAP|0942|INDV ASMT & INTERV NEW PA|Humana Medicare Advantage|HUMANA MA|||||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|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||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|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||0.61||| 97802|EAP|0942|INDV ASMT & INTERV NEW PA|Blue Cross PPO Specialty|BCBSTX PPO|||||0.61||| 97802|EAP|0942|INDV ASMT & INTERV NEW PA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.61||| 97802|EAP|0942|INDV ASMT & INTERV NEW PA|Managed Medicaid|MEDICAID SUPERIOR|||||0.61||| 97802|EAP|0942|INDV ASMT & INTERV NEW PA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.61||| 981|DRG||EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W MCC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|159,211.37|16621.01|16621.01|16621.01|||| 982|DRG||EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W CC|Managed Medicaid|MEDICAID SUPERIOR|27,580.05|27580.05|27580.05|27580.05|||| 99001|EAP|0300|HANDLING CHARGE|Managed Medicaid|MEDICAID SUPERIOR|||||27.75||| 99001|EAP|0300|HANDLING CHARGE|Medicare|MEDICARE ACUTE|27.75||||27.75||| 99001|EAP|0300|HANDLING CHARGE|Cigna|CIGNA|27.75||||||| 99195|EAP|0940|THERAPEUTIC PHLEBOTOMY|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||2.59||| 99195|EAP|0940|THERAPEUTIC PHLEBOTOMY|Blue Cross PPO Specialty|BCBSTX PPO|||||2.59||| 99195|EAP|0940|THERAPEUTIC PHLEBOTOMY|Medicare|MEDICARE ACUTE|||||2.59||| 99201|EAP|0761|TRIAGE 0-4HRS W/PRENATAL|Managed Medicaid|MEDICAID SUPERIOR|1,135.75||||1,135.75||| 99201|EAP|0761|TRIAGE 0-4HRS W/PRENATAL|Managed Medicaid|MEDICAID AMERIGROUP|314.50||||1,135.75||| 99201|EAP|0761|OUTPATIENT ROOM FEE 10 MI|Managed Medicaid|MEDICAID UNITED HEALTHCARE|314.50||||314.50||| 99201|EAP|0761|OUTPATIENT ROOM FEE 10 MI|Managed Medicaid|MEDICAID SUPERIOR|314.50||||314.50||| 99201|EAP|0761|OUTPATIENT ROOM FEE 10 MI|Managed Medicaid|MEDICAID AMERIGROUP|314.50||||314.50||| 99201|EAP|0761|OUTPATIENT ROOM FEE 10 MI|NON CONTRACTED|COMMERCIAL OTHER 2|314.50||||314.50||| 99201|EAP|0761|TRIAGE 0-4HRS W/PRENATAL|Medicaid|MEDICAID HMO|||||1,135.75||| 99201|EAP|0761|TRIAGE 0-4HRS W/PRENATAL|Medicaid|MEDICAID|1,135.75||||1,135.75||| 99201|EAP|0761|OUTPATIENT ROOM FEE 10 MI|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||314.50||| 99201|EAP|0761|OUTPATIENT ROOM FEE 10 MI|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||314.50||| 99201|EAP|0761|OUTPATIENT ROOM FEE 10 MI|Medicaid|MEDICAID TEXAS CHILDRENS|||||314.50||| 99201|EAP|0761|OUTPATIENT ROOM FEE 10 MI|NON CONTRACTED|COMMERCIAL OTHER 1|||||314.50||| 99201|EAP|0761|OUTPATIENT ROOM FEE 10 MI|Medicaid|MEDICAID HMO|||||314.50||| 99201|EAP|0761|OUTPATIENT ROOM FEE 10 MI|Medicaid|MEDICAID|314.50||||314.50||| 99201|EAP|0761|OUTPATIENT ROOM FEE 10 MI|Tricare|TRICARE EAST REGION|||||314.50||| 99201|EAP|0761|OUTPATIENT ROOM FEE 10 MI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||314.50||| 99201|EAP|0761|OUTPATIENT ROOM FEE 10 MI|United Healthcare|UNITED HEALTHCARE OTHER|314.50||||314.50||| 99201|EAP|0761|OUTPATIENT ROOM FEE 10 MI|United Healthcare|UNITED HEALTHCARE|||||314.50||| 99201|EAP|0761|OUTPATIENT ROOM FEE 10 MI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|314.50||||314.50||| 99201|EAP|0761|TRIAGE 0-4HRS W/PRENATAL|Blue Cross HMO Specialty|BCBSTX HMO|314.50||||1,135.75||| 99201|EAP|0761|OUTPATIENT ROOM FEE 10 MI|Blue Cross HMO Specialty|BCBSTX HMO|314.50||||314.50||| 99201|EAP|0761|OUTPATIENT ROOM FEE 10 MI|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||314.50||| 99201|EAP|0761|OUTPATIENT ROOM FEE 10 MI|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||314.50||| 99201|EAP|0761|OUTPATIENT ROOM FEE 10 MI|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|314.50||||314.50||| 99201|EAP|0761|OUTPATIENT ROOM FEE 10 MI|Blue Cross PPO Specialty|BCBSTX PPO|314.50||||314.50||| 99201|EAP|0761|OUTPATIENT ROOM FEE 10 MI|Cigna|CIGNA|||||314.50||| 99202|EAP|0424||Workers Compensation|WORKERS COMPENSATION OTHER|||||3.33||| 99203|EAP|0942|ENTEROSTOMAL THERAPY VISI|Medicare|MEDICARE ACUTE|||||418.75||| 99203|EAP|0761|EVAL/NP L-3 30 MIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3.10||| 99203|EAP|0942|ENTEROSTOMAL THERAPY VISI|United Healthcare|UNITED HEALTHCARE|||||418.75||| 99204|EAP|0761||Blue Cross PPO Specialty|BCBSTX PPO|||||409.50||| 99204|EAP|0761||Blue Cross HMO Specialty|BCBSTX HMO|||||409.50||| 99204|EAP|0761||Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||409.50||| 99204|EAP|0761||Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||409.50||| 99205|EAP|0761|EVAL/NP L-5 60 MIN|Managed Medicaid|MEDICAID SUPERIOR|||||679.75||| 99205|EAP|0761|EVAL/NP L-5 60 MIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||679.75||| 99205|EAP|0761|EVAL/NP L-5 60 MIN|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||679.75||| 99205|EAP|0761|EVAL/NP L-5 60 MIN|Blue Cross HMO Specialty|BCBSTX HMO|||||679.75||| 99205|EAP|0761|EVAL/NP L-5 60 MIN|Blue Cross PPO Specialty|BCBSTX PPO|||||679.75||| 99212|EAP|0761|TRT ROOM EST PT L-2 10MIN|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||3.65||| 99212|EAP|0761|TRT ROOM EST PT L-2 10MIN|Humana Medicare Advantage|HUMANA MA|||||3.65||| 99212|EAP|0761|TRT ROOM EST PT L-2 10MIN|Blue Cross PPO Specialty|BCBSTX PPO|||||3.65||| 99212|EAP|0761|TRT ROOM EST PT L-2 10MIN|Medicare|MEDICARE ACUTE|||||3.65||| 99213|EAP|0761|TREATMENT ROOM EST PT L-3|Aenta Medicare Advantage|AETNA MEDICARE MA|||||3.83||| 99213|EAP|0761|TREATMENT ROOM EST PT L-3|Blue Cross HMO Specialty|BCBSTX HMO|||||3.83||| 99213|EAP|0761|TREATMENT ROOM EST PT L-3|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||3.83||| 99213|EAP|0761|TREATMENT ROOM EST PT L-3|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||3.83||| 99213|EAP|0761|TREATMENT ROOM EST PT L-3|Blue Cross PPO Specialty|BCBSTX PPO|||||3.83||| 99213|EAP|0761|TREATMENT ROOM EST PT L-3|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||3.83||| 99214|EAP|0761||Blue Cross HMO Specialty|BCBSTX HMO|||||6.38||| 99214|EAP|0761||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||6.38||| 99214|EAP|0761||Medicare|MEDICARE ACUTE|||||6.38||| 99214|EAP|0761||Blue Cross PPO Specialty|BCBSTX PPO|||||6.38||| 99214|EAP|0761||Aenta Medicare Advantage|AETNA MEDICARE MA|||||6.38||| 99215|EAP|0761|TREATMENT ROOM EST PT L-5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||6.38||| 99215|EAP|0761|TREATMENT ROOM EST PT L-5|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||6.38||| 99215|EAP|0761|TREATMENT ROOM EST PT L-5|Blue Cross PPO Specialty|BCBSTX PPO|||||6.38||| 99215|EAP|0761|TREATMENT ROOM EST PT L-5|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||6.38||| 99281|EAP|0450|ER VISIT LEVEL 1|Medicare|MEDICARE ACUTE|||||223.50||| 99281|EAP|0450|ER VISIT LEVEL 1|NON CONTRACTED|COMMERCIAL OTHER 2|||||223.50||| 99281|EAP|0450|ER VISIT LEVEL 1|NON CONTRACTED|COMMERCIAL OTHER 1|||||223.50||| 99281|EAP|0450|ER VISIT LEVEL 1|Rusk State Hospital|RUSK STATE HOSP|||||223.50||| 99281|EAP|0450|ER VISIT LEVEL 1|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||223.50||| 99281|EAP|0450|ER VISIT LEVEL 1|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||223.50||| 99281|EAP|0450|ER VISIT LEVEL 1|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||223.50||| 99281|EAP|0450|ER VISIT LEVEL 1|Medicaid|MEDICAID HMO|||||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|||||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|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|Medicaid|MEDICAID TEXAS CHILDRENS|||||223.50||| 99281|EAP|0450|ER VISIT LEVEL 1|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||223.50||| 99281|EAP|0450|ER VISIT LEVEL 1|Blue Cross PPO Specialty|BCBSTX OTHER|||||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|Blue Cross HMO Specialty|BCBSTX HMO|||||223.50||| 99281|EAP|0450|ER VISIT LEVEL 1|Humana Medicare Advantage|HUMANA MA|||||223.50||| 99281|EAP|0450|ER VISIT LEVEL 1|Aetna|AETNA PPO|||||223.50||| 99281|EAP|0450|ER VISIT LEVEL 1|Blue Cross PPO Specialty|BCBSTX PPO|||||223.50||| 99281|EAP|0450|ER VISIT LEVEL 1|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||223.50||| 99281|EAP|0450|ER VISIT LEVEL 1|Workers Compensation|WORKERS COMPENSATION OTHER|||||223.50||| 99281|EAP|0450|ER VISIT LEVEL 1|Workers Compensation|UT EMPLOYEE INJURY|||||223.50||| 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|||||223.50||| 99281|EAP|0450|ER VISIT LEVEL 1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||223.50||| 99281|EAP|0450|ER VISIT LEVEL 1|Managed Medicaid|MEDICAID AMERIGROUP|||||223.50||| 99281|EAP|0450|ER VISIT LEVEL 1|Managed Medicaid|MEDICAID SUPERIOR|223.50||||223.50||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|Blue Cross HMO Specialty|BCBSTX HMO|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|Aetna|AETNA PPO|||||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|Blue Cross PPO Specialty|BCBSTX PPO|||||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|Humana Medicare Advantage|HUMANA MA|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|Veterans Affairs|VETERANS ADMINISTRATION|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2|United Healthcare|UNITED HEALTHCARE OTHER|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|Workers Compensation|WORKERS COMPENSATION OTHER|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2|Workers Compensation|UT EMPLOYEE INJURY|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2|Workers Compensation|WORKERS COMPENSATION OTHER|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2|United Healthcare|UNITED HEALTHCARE|||||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|Cigna|CIGNA|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|Managed Medicaid|MEDICAID SUPERIOR|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|United Medicare Advantage|UHC MEDICARE GOLD MA|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2|Blue Cross PPO Specialty|BCBSTX OTHER|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.78||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|Managed Medicaid|MEDICAID AMERIGROUP|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2|Managed Medicaid|MEDICAID SUPERIOR|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2|Managed Medicaid|MEDICAID AMERIGROUP|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|3.78||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|Medicaid|MEDICAID PCCM|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|Medicaid|MEDICAID HMO|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|Medicaid|MEDICAID|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2|Medicaid|MEDICAID TEXAS CHILDRENS|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2|Blue Cross HMO Specialty|BCBSTX HMO|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|Medicaid|MEDICAID TEXAS CHILDRENS|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2|Medicaid|MEDICAID HMO|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2|Medicaid|MEDICAID|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|NON CONTRACTED|COMMERCIAL OTHER 1|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2|NON CONTRACTED|COMMERCIAL OTHER 1|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2|United Medicare Advantage|UHC MEDICARE GOLD MA|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|PHCS|HUMANA INSURANCE|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2|Medicare|MEDICARE ACUTE|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|Medicare|MEDICARE ACUTE|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|Tricare|TRICARE EAST REGION|||||3.78||| 99282|EAP|0450|ER VISIT LEVEL 2 WITH PRO|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||3.78||| 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 WITH PRO|Blue Cross PPO Specialty|BCBSTX PPO|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Blue Cross PPO Specialty|BCBSTX PPO|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Blue Cross PPO Specialty|BCBSTX OTHER|||||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|Cigna|CIGNA|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Cigna|CIGNA|||||11.00||| 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|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|Aenta Medicare Advantage|AETNA MEDICARE MA|11.00||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Aenta Medicare Advantage|AETNA MEDICARE MA|11.00||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|Blue Cross HMO Specialty|BCBSTX HMO|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Humana Medicare Advantage|HUMANA MA|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|Blue Cross PPO Specialty|BCBSTX OTHER|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Blue Cross HMO Specialty|BCBSTX HMO|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|Access Direct Platinum|HEALTHFIRST TPA UMR|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Access Direct Platinum|HEALTHFIRST TPA UMR|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|Workers Compensation|UT EMPLOYEE INJURY|||||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 WITH PRO|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||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|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|Aetna|ZZZZZ AETNA|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Aetna|AETNA PPO|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|Aetna|AETNA OTHER|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Aetna|AETNA OTHER|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|Medicaid|MEDICAID TEXAS CHILDRENS|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|Medicaid|MEDICAID PCCM|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|Medicaid|MEDICAID HMO|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|Medicaid|MEDICAID|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Medicaid|MEDICAID PCCM|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Medicaid|MEDICAID HMO|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Medicaid|MEDICAID|||||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|NON CONTRACTED|COMMERCIAL OTHER 1|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|Rusk State Hospital|RUSK STATE HOSP|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Medicaid Out of State|MEDICAID LOUISIANA|||||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 EAST REGION|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|Medicare|MEDICARE ACUTE|11.00||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Medicare|MEDICARE ACUTE|11.00||||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|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|Managed Medicare|WELLCARE CHOICE MA|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Managed Medicare|HEALTHSPRING 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 WITH PRO|Managed Medicaid|MEDICAID SUPERIOR|11.00||||11.00||| 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|Managed Medicaid|MEDICAID AMERIGROUP|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Rusk State Hospital|RUSK STATE HOSP|||||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 SUPERIOR|11.00||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Managed Medicaid|MEDICAID AMERIGROUP|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|United Medicare Advantage|UHC MEDICARE GOLD MA|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|11.00||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Medicaid|MEDICAID TEXAS CHILDRENS|||||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|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|11.00||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Veterans Affairs|VETERANS ADMINISTRATION|||||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 OTHER|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|United Healthcare|UNITED HEALTHCARE|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3 WITH PRO|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|United Healthcare|UNITED HEALTHCARE OTHER|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|United Healthcare|UNITED HEALTHCARE|||||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|TML GROUP BENEFITS|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Workers Compensation|UT EMPLOYEE INJURY|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||11.00||| 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|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||11.00||| 99283|EAP|0450|ER VISIT LEVEL 3|Workers Compensation|WORKERS COMPENSATION OTHER|||||11.00||| 99284|EAP|0450|ER VISIT LEVEL 4|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Aenta Medicare Advantage|AETNA MEDICARE MA|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Blue Cross HMO Specialty|BCBSTX HMO|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4|Blue Cross HMO Specialty|BCBSTX HMO|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Access Direct Platinum|HEALTHFIRST TPA UMR|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Aetna|AETNA OTHER|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4|Aetna|AETNA OTHER|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Blue Cross PPO Specialty|BCBSTX PPO|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Blue Cross PPO Specialty|BCBSTX OTHER|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4|Blue Cross PPO Specialty|BCBSTX PPO|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4|Blue Cross PPO Specialty|BCBSTX OTHER|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Humana Medicare Advantage|HUMANA MA|18.20||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4|Humana Medicare Advantage|HUMANA MA|18.20||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Cigna|CIGNA|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|United Medicare Advantage|UHC MEDICARE GOLD MA|18.20||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4|United Medicare Advantage|UHC MEDICARE GOLD MA|18.20||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4|Workers Compensation|UT EMPLOYEE INJURY|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Veterans Affairs|VETERANS ADMINISTRATION|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|United Healthcare|UNITED HEALTHCARE OTHER|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|United Healthcare|UNITED HEALTHCARE|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|United Healthcare|GEHA|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4|United Healthcare|UNITED HEALTHCARE OTHER|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4|United Healthcare|UNITED HEALTHCARE|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Workers Compensation|WORKERS COMPENSATION OTHER|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4|Workers Compensation|WORKERS COMPENSATION OTHER|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4|United Medicare Advantage|AARP UHC WEST COMPLETE MA|18.20||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Managed Medicare|HEALTHSPRING MA|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Managed Medicare|BCBS MEDICARE PPO MA|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|United Medicare Advantage|AARP UHC WEST COMPLETE MA|18.20||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4|Managed Medicare|HEALTHSPRING MA|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4|Cigna|CIGNA|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Managed Medicaid|MEDICAID SUPERIOR|18.20||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Managed Medicaid|MEDICAID AMERIGROUP|18.20||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4|Managed Medicaid|MEDICAID SUPERIOR|18.20||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4|Managed Medicaid|MEDICAID AMERIGROUP|18.20||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Medicaid|MEDICAID TEXAS CHILDRENS|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Aetna|AETNA PPO|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Medicaid|MEDICAID PCCM|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Medicaid|MEDICAID HMO|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Medicaid|MEDICAID|10.05||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4|Access Direct Platinum|HEALTHFIRST TPA UMR|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4|Medicaid|MEDICAID|10.05||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4|Medicaid|MEDICAID TEXAS CHILDRENS|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|NON CONTRACTED|COMMERCIAL OTHER 1|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4|NON CONTRACTED|COMMERCIAL OTHER 1|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|PHCS|HUMANA INSURANCE|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Rusk State Hospital|RUSK STATE HOSP|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4|Rusk State Hospital|RUSK STATE HOSP|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Tricare|TRICARE EAST REGION|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4|Tricare|TRICARE EAST REGION|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|Medicare|MEDICARE ACUTE|18.20||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4|Medicare|MEDICARE ACUTE|18.20||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4 WITH PRO|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||18.20||| 99284|EAP|0450|ER VISIT LEVEL 4|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||18.20||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Medicaid|SUPERIOR HEALTHPLAN CHIP|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Medicaid|MEDICAID HMO|||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Medicaid|MEDICAID|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Medicaid|COUNTY INDIGENT HEALTH OTHER|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5|Medicaid|MOLINA HEALTHCARE OF TEXAS|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5|Medicaid|MEDICAID TEXAS CHILDRENS|||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5|Medicaid|MEDICAID|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|NON CONTRACTED|COMMERCIAL OTHER 2|||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|NON CONTRACTED|COMMERCIAL OTHER 1|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Rusk State Hospital|RUSK STATE HOSP|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5|Rusk State Hospital|RUSK STATE HOSP|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Tricare|TRICARE EAST REGION|||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5|Tricare|TRICARE EAST REGION|||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Medicare|MEDICARE PART B ONLY IP|27.40||||||| 99285|EAP|0450|ER VISIT LEVEL 5|Medicare|MEDICARE ACUTE|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|UTMB|UTMB CORRECTIONAL MANAGED CARE|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5|UTMB|UTMB CORRECTIONAL MANAGED CARE|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Managed Medicare|HOSPICE OF EAST TEXAS|27.40||||||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Managed Medicare|HEALTHSPRING MA|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Managed Medicaid|MEDICAID UNITED HEALTHCARE|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Managed Medicaid|MEDICAID SUPERIOR|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Managed Medicaid|MEDICAID AMERIGROUP|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5|Managed Medicaid|MEDICAID UNITED HEALTHCARE|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5|Managed Medicaid|MEDICAID AMERIGROUP|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Workers Compensation|UT EMPLOYEE INJURY|27.40||||||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|United Medicare Advantage|UHC MEDICARE GOLD MA|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5|Managed Medicaid|MEDICAID SUPERIOR|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|United Medicare Advantage|AARP UHC WEST COMPLETE MA|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5|United Medicare Advantage|UHC MEDICARE GOLD MA|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5|United Medicare Advantage|AARP UHC WEST COMPLETE MA|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Veterans Affairs|VETERANS ADMINISTRATION|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|United Healthcare|UNITED HEALTHCARE OTHER|||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|United Healthcare|UNITED HEALTHCARE|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|United Healthcare|UMR UNITED MEDICAL RESOURCES|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Medicare|MEDICARE ACUTE|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|United Healthcare|TML GROUP BENEFITS|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5|United Healthcare|UNITED HEALTHCARE OTHER|||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5|United Healthcare|UMR UNITED MEDICAL RESOURCES|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Workers Compensation|WORKERS COMPENSATION OTHER|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Blue Cross PPO Specialty|BCBSTX PPO|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Blue Cross PPO Specialty|BCBSTX OTHER|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5|Blue Cross PPO Specialty|BCBSTX PPO|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5|Blue Cross PPO Specialty|BCBSTX OTHER|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Humana Medicare Advantage|HUMANA MA|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5|Humana Medicare Advantage|HUMANA MA|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Cigna|CIGNA|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Medicaid|MOLINA HEALTHCARE OF TEXAS|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Cigna|CIGNA|27.40||||||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Cigna|CIGNA|||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Medicaid|MEDICAID TEXAS CHILDRENS|||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Aenta Medicare Advantage|AETNA MEDICARE MA|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5|Aenta Medicare Advantage|AETNA MEDICARE MA|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Blue Cross HMO Specialty|BCBSTX HMO|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5|Blue Cross HMO Specialty|BCBSTX HMO|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Aetna|AETNA OTHER|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5 WITH PRO|Aetna|AETNA PPO|27.40||||27.40||| 99285|EAP|0450|ER VISIT LEVEL 5|Aetna|AETNA PPO|27.40||||27.40||| 99291|EAP|0450|CRITICAL CARE FIRST HOUR|Aenta Medicare Advantage|AETNA MEDICARE MA|||||2,302.75||| 99291|EAP|0450|CRITICAL CARE FIRST HOUR|Blue Cross HMO Specialty|BCBSTX HMO|||||2,302.75||| 99291|EAP|0450|CRITICAL CARE FIRST HOUR|Humana Medicare Advantage|HUMANA MA|2,302.75||||2,302.75||| 99291|EAP|0450|CRITICAL CARE FIRST HOUR|United Medicare Advantage|UHC MEDICARE GOLD MA|||||2,302.75||| 99291|EAP|0450|CRITICAL CARE FIRST HOUR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2,302.75||| 99291|EAP|0450|CRITICAL CARE FIRST HOUR|Blue Cross PPO Specialty|BCBSTX PPO|||||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|Veterans Affairs|VETERANS ADMINISTRATION|||||2,302.75||| 99291|EAP|0450|CRITICAL CARE FIRST HOUR|United Healthcare|UNITED HEALTHCARE|2,302.75||||||| 99291|EAP|0450|CRITICAL CARE FIRST HOUR|Workers Compensation|WORKERS COMPENSATION OTHER|||||2,302.75||| 99291|EAP|0450|CRITICAL CARE FIRST HOUR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||2,302.75||| 99291|EAP|0450|CRITICAL CARE FIRST HOUR|Managed Medicaid|MEDICAID SUPERIOR|2,302.75||||2,302.75||| 99291|EAP|0450|CRITICAL CARE FIRST HOUR|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2,302.75||||2,302.75||| 99291|EAP|0450|CRITICAL CARE FIRST HOUR|Medicaid|MEDICAID|2,302.75||||2,302.75||| 99291|EAP|0450|CRITICAL CARE FIRST HOUR|Rusk State Hospital|RUSK STATE HOSP|||||2,302.75||| 99291|EAP|0450|CRITICAL CARE FIRST HOUR|Medicare|MEDICARE ACUTE|2,302.75||||2,302.75||| 99291|EAP|0450|CRITICAL CARE FIRST HOUR|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||2,302.75||| 998|DRG||PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS|Medicaid|MEDICAID|30,908.50|5900.72|5900.72|5900.72|||| A4216|ERX|0250|WATER FOR INJ.,STERILE 10|United Healthcare|UNITED HEALTHCARE|12.50||||||| A4216|ERX|0250|WATER FOR INJ.,STERILE 10|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|12.50||||||| A4216|ERX|0250|WATER FOR INJ.,STERILE 10|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|12.50||||||| A4216|ERX|0250|WATER FOR INJ.,STERILE 10|United Medicare Advantage|AARP UHC WEST COMPLETE MA|12.50||||12.50||| A4216|ERX|0250|WATER FOR INJ.,STERILE 10|Humana Medicare Advantage|HUMANA MA|12.50||||||| A4216|ERX|0250|WATER FOR INJ.,STERILE 10|Aenta Medicare Advantage|AETNA MEDICARE MA|12.50||||||| A4216|ERX|0250|WATER FOR INJ.,STERILE 10|Blue Cross HMO Specialty|BCBSTX HMO|12.50||||12.50||| A4216|ERX|0250|WATER FOR INJ.,STERILE 10|Medicare|MEDICARE ACUTE|12.50||||12.50||| A4216|ERX|0250|WATER FOR INJ.,STERILE 10|Rusk State Hospital|RUSK STATE HOSP|12.50||||12.50||| A4216|ERX|0250|WATER FOR INJ.,STERILE 10|UTMB|UTMB CORRECTIONAL MANAGED CARE|12.50||||12.50||| A4216|ERX|0250|WATER FOR INJ.,STERILE 10|Managed Medicare|HEALTHSPRING MA|12.50||||||| A4216|ERX|0250|WATER FOR INJ.,STERILE 10|Managed Medicaid|MEDICAID SUPERIOR|12.50||||12.50||| A4216|ERX|0250|WATER FOR INJ.,STERILE 10|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|12.50||||12.50||| A4216|ERX|0250|WATER FOR INJ.,STERILE 10|Managed Medicaid|MEDICAID AMERIGROUP|12.50||||||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||116.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Managed Medicare|HEALTHSPRING MA|118.75||||118.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|118.75||||118.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|118.75||||116.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Managed Medicaid|MEDICAID SUPERIOR|118.75||||118.75||| 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|Managed Medicaid|MEDICAID SUPERIOR|116.75||||116.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Managed Medicaid|MEDICAID AMERIGROUP|116.75||||116.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|116.75||||116.75||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Medicaid|MEDICAID|||||12.50||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Medicaid|MEDICAID HMO|||||116.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||116.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Medicaid|MEDICAID HMO|||||118.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Medicaid|MEDICAID|118.75||||116.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||118.75||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|12.50||||12.50||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|NON CONTRACTED|COMMERCIAL OTHER 1|118.75||||116.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|NON CONTRACTED|COMMERCIAL OTHER 1|116.75||||116.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Medicare|MEDICARE ACUTE|118.75||||118.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Medicare|MEDICARE PART B ONLY IP|116.75||||||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Medicare|MEDICARE ACUTE|116.75||||116.75||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Rusk State Hospital|RUSK STATE HOSP|12.50||||12.50||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Rusk State Hospital|RUSK STATE HOSP|118.75||||116.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Rusk State Hospital|RUSK STATE HOSP|116.75||||116.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||118.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Tricare|TRICARE EAST REGION|||||116.75||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||12.50||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|118.75||||118.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|118.75||||118.75||| 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|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|116.75||||116.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|118.75||||||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|116.75||||||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Blue Cross PPO Specialty|BCBSTX PPO|118.75||||118.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Aenta Medicare Advantage|AETNA MEDICARE MA|118.75||||116.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|UTMB|UTMB CORRECTIONAL MANAGED CARE|116.75||||116.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Aenta Medicare Advantage|AETNA MEDICARE MA|116.75||||116.75||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Blue Cross HMO Specialty|BCBSTX HMO|||||12.50||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Blue Cross HMO Specialty|BCBSTX HMO|118.75||||118.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Blue Cross HMO Specialty|BCBSTX HMO|116.75||||116.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||116.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Aetna|AETNA OTHER|||||116.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Aetna|AETNA PPO|116.75||||||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Blue Cross PPO Specialty|BCBSTX PPO|116.75||||116.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Blue Cross PPO Specialty|BCBSTX OTHER|116.75||||116.75||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Humana Medicare Advantage|HUMANA MA|12.50||||12.50||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Humana Medicare Advantage|HUMANA MA|118.75||||118.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Humana Medicare Advantage|HUMANA MA|116.75||||116.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|118.75||||||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Medicare|MEDICARE ACUTE|12.50||||12.50||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Brinson Benefits|THE HEALTH PLAN SMITH CO|116.75||||||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Cigna|CIGNA|116.75||||116.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Cigna|CIGNA|||||118.75||| 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|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||118.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||116.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Veterans Affairs|VETERANS ADMINISTRATION|118.75||||116.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Veterans Affairs|VETERANS ADMINISTRATION|116.75||||116.75||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|Managed Medicaid|MEDICAID SUPERIOR|||||12.50||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Medicaid|MEDICAID|116.75||||116.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Workers Compensation|WORKERS COMPENSATION OTHER|118.75||||118.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Workers Compensation|UT EMPLOYEE INJURY|118.75||||||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Workers Compensation|WORKERS COMPENSATION OTHER|118.75||||116.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|116.75||||||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Managed Medicaid|MEDICAID AMERIGROUP|118.75||||118.75||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|United Medicare Advantage|UHC MEDICARE GOLD MA|12.50||||||| A4218|ERX|0250|SODIUM CHLORIDE 0.9% 10ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|12.50||||12.50||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|United Healthcare|UNITED HEALTHCARE|116.75||||||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|United Healthcare|UNITED HEALTHCARE OTHER|116.75||||116.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|Managed Medicare|HEALTHSPRING MA|116.75||||118.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|United Healthcare|TML GROUP BENEFITS|116.75||||||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|United Healthcare|UNITED HEALTHCARE|||||118.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|United Medicare Advantage|AARP UHC WEST COMPLETE MA|116.75||||116.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|United Medicare Advantage|UHC MEDICARE GOLD MA|118.75||||116.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|United Medicare Advantage|UHC MEDICARE GOLD MA|116.75||||116.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|United Healthcare|UNITED HEALTHCARE OTHER|116.75||||118.75||| 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 DUAL COMPLETE HMO SNP MA|116.75||||116.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 100M|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|116.75||||||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|118.75||||116.75||| A4218|ERX|0258|SODIUM CHLORIDE 0.9% 50ML|United Healthcare|UNITED HEALTHCARE|118.75||||||| 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|United Healthcare|UNITED HEALTHCARE OTHER|||||0.19||| A4320|EAP|0274|TRAY,IRRIGATE 70CC DISP E|United Healthcare|UNITED HEALTHCARE|0.19||||||| A4320|EAP|0274|TRAY,IRRIGATE 70CC DISP E|Veterans Affairs|VETERANS ADMINISTRATION|0.19||||||| A4320|EAP|0274|TRAY,IRRIGATE 70CC DISP E|Workers Compensation|WORKERS COMPENSATION OTHER|0.19||||0.19||| A4320|EAP|0274|TRAY,IRRIGATE 70CC DISP E|Humana Medicare Advantage|HUMANA MA|0.19||||0.19||| A4320|EAP|0274|TRAY,IRRIGATE 70CC DISP E|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||0.19||| A4320|EAP|0274|TRAY,IRRIGATE 70CC DISP E|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.19||||0.19||| A4320|EAP|0274|TRAY,IRRIGATE 70CC DISP E|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.19||||||| A4320|EAP|0274|TRAY,IRRIGATE 70CC DISP E|Aenta Medicare Advantage|AETNA MEDICARE MA|0.19||||||| A4320|EAP|0274|TRAY,IRRIGATE 70CC DISP E|Blue Cross HMO Specialty|BCBSTX HMO|0.19||||0.19||| A4320|EAP|0274|TRAY,IRRIGATE 70CC DISP E|Blue Cross PPO Specialty|BCBSTX PPO|||||0.19||| A4320|EAP|0274|TRAY,IRRIGATE 70CC DISP E|Blue Cross PPO Specialty|BCBSTX OTHER|||||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|Rusk State Hospital|RUSK STATE HOSP|0.19||||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|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.19||||||| A4320|EAP|0274|TRAY,IRRIGATE 70CC DISP E|Medicaid|MEDICAID|0.19||||||| A4353|EAP|0274|TRAY,CATH W-NON RET CATH|Managed Medicaid|MEDICAID SUPERIOR|0.73||||0.73||| A4353|EAP|0274|TRAY,CATH W-NON RET CATH|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.73||||0.73||| A4353|EAP|0274|KIT,INFANT CATH 5FR DISP|Managed Medicaid|MEDICAID SUPERIOR|0.73||||40.75||| A4353|EAP|0274|KIT,INFANT CATH 5FR DISP|Managed Medicaid|MEDICAID AMERIGROUP|0.73||||40.75||| A4353|EAP|0274|KIT CATH FEMALE 8FR DISP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.19||||0.19||| A4353|EAP|0274|KIT CATH FEMALE 8FR DISP|Managed Medicaid|MEDICAID SUPERIOR|40.75||||0.19||| A4353|EAP|0274|KIT CATH FEMALE 8FR DISP|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.19||||0.19||| A4353|EAP|0274|TRAY,CATH W-NON RET CATH|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.73||||0.73||| A4353|EAP|0274|TRAY,CATH W-NON RET CATH|Managed Medicare|HEALTHSPRING MA|0.73||||||| A4353|EAP|0274|KIT CATH FEMALE 8FR DISP|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.19||||0.19||| A4353|EAP|0274|KIT,INFANT CATH 5FR DISP|Medicaid|MEDICAID|0.73||||40.75||| A4353|EAP|0274|KIT,INFANT CATH 5FR DISP|Medicaid|MEDICAID HMO|||||40.75||| A4353|EAP|0274|KIT,INFANT CATH 5FR DISP|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||40.75||| A4353|EAP|0274|KIT CATH FEMALE 8FR DISP|Medicaid|MEDICAID|40.75||||0.19||| A4353|EAP|0274|TRAY,CATH W-NON RET CATH|Medicare|MEDICARE ACUTE|0.73||||0.73||| A4353|EAP|0274|KIT,INFANT CATH 5FR DISP|Medicare|MEDICARE ACUTE|40.75||||40.75||| A4353|EAP|0274|KIT CATH FEMALE 8FR DISP|Medicare|MEDICARE ACUTE|0.19||||0.19||| A4353|EAP|0274|TRAY,CATH W-NON RET CATH|Rusk State Hospital|RUSK STATE HOSP|0.73||||0.73||| A4353|EAP|0274|KIT CATH FEMALE 8FR DISP|Rusk State Hospital|RUSK STATE HOSP|0.19||||0.19||| A4353|EAP|0274|KIT CATH FEMALE 8FR DISP|Tricare|TRICARE EAST REGION|||||0.19||| A4353|EAP|0274|TRAY,CATH W-NON RET CATH|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||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|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.73||| A4353|EAP|0274|KIT CATH FEMALE 8FR DISP|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.19||| A4353|EAP|0274|TRAY,CATH W-NON RET CATH|Aenta Medicare Advantage|AETNA MEDICARE MA|0.73||||0.73||| A4353|EAP|0274|KIT CATH FEMALE 8FR DISP|Aenta Medicare Advantage|AETNA MEDICARE MA|0.73||||0.19||| A4353|EAP|0274|KIT CATH FEMALE 8FR DISP|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.19||||||| A4353|EAP|0274|TRAY,CATH W-NON RET CATH|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.73||||||| A4353|EAP|0274|KIT CATH FEMALE 8FR DISP|Medicaid|MEDICAID HMO|||||0.19||| A4353|EAP|0274|KIT,INFANT CATH 5FR DISP|Blue Cross PPO Specialty|BCBSTX PPO|0.73||||40.75||| A4353|EAP|0274|TRAY,CATH W-NON RET CATH|Blue Cross HMO Specialty|BCBSTX HMO|0.19||||0.73||| A4353|EAP|0274|KIT CATH FEMALE 8FR DISP|Blue Cross HMO Specialty|BCBSTX HMO|0.19||||0.19||| A4353|EAP|0274|TRAY,CATH W-NON RET CATH|Aetna|AETNA OTHER|||||0.73||| A4353|EAP|0274|TRAY,CATH W-NON RET CATH|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.73||| A4353|EAP|0274|TRAY,CATH W-NON RET CATH|Blue Cross PPO Specialty|BCBSTX PPO|0.73||||0.73||| A4353|EAP|0274|TRAY,CATH W-NON RET CATH|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.73||| A4353|EAP|0274|KIT,INFANT CATH 5FR DISP|Blue Cross PPO Specialty|BCBSTX OTHER|||||40.75||| A4353|EAP|0274|TRAY,CATH W-NON RET CATH|Humana Medicare Advantage|HUMANA MA|0.73||||0.73||| A4353|EAP|0274|KIT CATH FEMALE 8FR DISP|Managed Medicaid|MEDICAID AMERIGROUP|0.19||||0.19||| A4353|EAP|0274|KIT CATH FEMALE 8FR DISP|Humana Medicare Advantage|HUMANA MA|0.19||||0.19||| A4353|EAP|0274|KIT,INFANT CATH 5FR DISP|Cigna|CIGNA|||||40.75||| A4353|EAP|0274|KIT CATH FEMALE 8FR DISP|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||0.19||| A4353|EAP|0274|TRAY,CATH W-NON RET CATH|United Medicare Advantage|AARP UHC WEST COMPLETE 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|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.73||||0.73||| A4353|EAP|0274|TRAY,CATH W-NON RET CATH|United Medicare Advantage|UHC MEDICARE GOLD MA|0.73||||0.73||| A4353|EAP|0274|TRAY,CATH W-NON RET CATH|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.73||||0.73||| A4353|EAP|0274|KIT CATH FEMALE 8FR DISP|United Medicare Advantage|UHC MEDICARE GOLD MA|0.19||||0.19||| A4353|EAP|0274|KIT CATH FEMALE 8FR DISP|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.19||||0.19||| A4353|EAP|0274|TRAY,CATH W-NON RET CATH|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||0.73||| A4353|EAP|0274|TRAY,CATH W-NON RET CATH|United Healthcare|UNITED HEALTHCARE OTHER|||||0.73||| A4353|EAP|0274|TRAY,CATH W-NON RET CATH|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||0.73||| A4353|EAP|0274|KIT,INFANT CATH 5FR DISP|United Healthcare|UNITED HEALTHCARE|||||40.75||| A4353|EAP|0274|KIT CATH FEMALE 8FR DISP|United Healthcare|UNITED HEALTHCARE|0.19||||||| A4353|EAP|0274|TRAY,CATH W-NON RET CATH|Veterans Affairs|VETERANS ADMINISTRATION|||||0.73||| A4353|EAP|0274|TRAY,CATH W-NON RET CATH|Workers Compensation|WORKERS COMPENSATION OTHER|||||0.73||| A4550|EAP|0270||United Healthcare|UNITED HEALTHCARE OTHER|||||29.50||| A4550|EAP|0270||United Healthcare|UNITED HEALTHCARE|||||29.50||| A4550|EAP|0270||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||29.50||| A4550|EAP|0272|SET,INFUSION W/Y SITE 20G|Blue Cross PPO Specialty|BCBSTX PPO|||||61.50||| A4550|EAP|0270||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|29.50||||29.50||| A4550|EAP|0272|TRAY,SUTURE-SMALL DISP EA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||2.10||| A4550|EAP|0270||Blue Cross HMO Specialty|BCBSTX HMO|||||29.50||| A4550|EAP|0270||Aetna|AETNA PPO|||||29.50||| A4550|EAP|0270||Blue Cross PPO Specialty|BCBSTX PPO|||||29.50||| A4550|EAP|0272|TRAY,SUTURE-SMALL DISP EA|Blue Cross PPO Specialty|BCBSTX PPO|||||2.10||| A4550|EAP|0272|TRAY,DRESSING CENTRAL LIN|Blue Cross PPO Specialty|BCBSTX PPO|||||79.25||| A4550|EAP|0272|TRAY,DRESSING CENTRAL LIN|Managed Medicare|HEALTHSPRING MA|79.25||||||| A4550|EAP|0270||Medicaid|SUPERIOR HEALTHPLAN CHIP|||||29.50||| A4550|EAP|0272|TRAY,DRESSING CENTRAL LIN|Medicaid|MEDICAID|79.25||||||| A4565|EAP|0271|SLING ARM DISP SMALL EA|Medicare|MEDICARE ACUTE|||||43.25||| A4565|EAP|0271|SLING ARM MEDIUM EA|Humana Medicare Advantage|HUMANA MA|||||43.25||| A4565|EAP|0271|SLING ARM MEDIUM EA|Blue Cross PPO Specialty|BCBSTX PPO|||||43.25||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|United Medicare Advantage|UHC MEDICARE GOLD MA|||||310.25||| A4649|EAP|0270|SUCTION,YANKAUER DISP EA|United Healthcare|UNITED HEALTHCARE|||||15.25||| A4649|EAP|0272||United Healthcare|UNITED HEALTHCARE|||||8.75||| A4649|EAP|0270|SUCTION,YANKAUER DISP EA|Workers Compensation|WORKERS COMPENSATION OTHER|||||15.25||| A4649|EAP|0270||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||25.75||| A4649|EAP|0270|SUCTION,YANKAUER DISP EA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||15.25||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||310.25||| A4649|EAP|0272|LEGGINGS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||28.75||| A4649|EAP|0272|DRAPE HYSTEROSCOPY/D&C DI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||61.50||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|Aenta Medicare Advantage|AETNA MEDICARE MA|310.25||||||| A4649|EAP|0272|RETRACTOR RING DISP (LONE|Aenta Medicare Advantage|AETNA MEDICARE MA|101.75||||||| A4649|EAP|0270||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|25.75||||25.75||| A4649|EAP|0270|SUCTION,YANKAUER DISP EA|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||15.25||| A4649|EAP|0270||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1,051.50||||1,051.50||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|310.25||||310.25||| A4649|EAP|0272|BARRIER HOOD|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|69.75||||||| A4649|EAP|0270||Blue Cross HMO Specialty|BCBSTX HMO|||||1,051.50||| A4649|EAP|0270|SUCTION,YANKAUER DISP EA|Blue Cross HMO Specialty|BCBSTX HMO|||||15.25||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|Blue Cross HMO Specialty|BCBSTX HMO|||||310.25||| A4649|EAP|0270||Aetna|AETNA PPO|||||1,051.50||| A4649|EAP|0270||Blue Cross HMO Specialty|BCBSTX HMO|||||25.75||| A4649|EAP|0270|SUCTION,YANKAUER DISP EA|Blue Cross PPO Specialty|BCBSTX PPO|||||15.25||| A4649|EAP|0270|SUCTION,YANKAUER DISP EA|Blue Cross PPO Specialty|BCBSTX OTHER|||||15.25||| A4649|EAP|0270||Blue Cross PPO Specialty|BCBSTX PPO|||||25.75||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|Blue Cross PPO Specialty|BCBSTX PPO|||||310.25||| A4649|EAP|0270|SUCTION,YANKAUER DISP EA|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1,051.50||||15.25||| A4649|EAP|0272|ELASTIC STAYS (LONESTAR)|Aenta Medicare Advantage|AETNA MEDICARE MA|109.75||||||| A4649|EAP|0272|AMNIHOOK OB DISP EA|Blue Cross PPO Specialty|BCBSTX PPO|0.19||||||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|Humana Medicare Advantage|HUMANA MA|310.25||||310.25||| A4649|EAP|0272|BARRIER HOOD|Humana Medicare Advantage|HUMANA MA|69.75||||||| A4649|EAP|0270|SUCTION,YANKAUER DISP EA|Brinson Benefits|THE HEALTH PLAN SMITH CO|||||15.25||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|Managed Medicaid|MEDICAID SUPERIOR|310.25||||||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|310.25||||||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|310.25||||310.25||| A4649|EAP|0272|AMNIHOOK OB DISP EA|Managed Medicaid|MEDICAID SUPERIOR|0.19||||||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||310.25||| A4649|EAP|0272|ALEXIS C-SECTION RETRACT/|Managed Medicaid|MEDICAID SUPERIOR|1.12||||||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|Managed Medicare|HEALTHSPRING MA|310.25||||||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||310.25||| A4649|EAP|0272|LAPAROSCOPIC CHOLECYSTECT|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||49.75||| A4649|EAP|0270|SUCTION,YANKAUER DISP EA|United Healthcare|UNITED HEALTHCARE OTHER|||||15.25||| A4649|EAP|0272|SURGICEL 4X8|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||117.75||| A4649|EAP|0272|LAPAROSCOPIC CHOLECYSTECT|Managed Medicare|HEALTHSPRING MA|49.75||||||| A4649|EAP|0270|SUCTION,YANKAUER DISP EA|Medicaid|MEDICAID|||||15.25||| A4649|EAP|0271|AIRWAY 60MM DISP EA NONST|Medicaid|MEDICAID|||||0.01||| A4649|EAP|0272||Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.21||| A4649|EAP|0271|GARMENT HIP/CALF DISP EA|Medicare|MEDICARE ACUTE|310.25||||310.25||| A4649|EAP|0270|SUCTION,YANKAUER DISP EA|Tricare|TRICARE EAST REGION|||||15.25||| A4649|EAP|0272||Tricare|TRICARE EAST REGION|||||0.21||| A4649|EAP|0270|SUCTION,YANKAUER DISP EA|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||15.25||| A4649|EAP|0272||UTMB|UTMB CORRECTIONAL MANAGED CARE|||||83.25||| A4649|EAP|0272||UTMB|UTMB CORRECTIONAL MANAGED CARE|||||0.21||| A6258|EAP|0272||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||21.75||| A6266|EAP|0272||Managed Medicaid|MEDICAID SUPERIOR|||||60.25||| A6402|EAP|0272|SPONGES GAUZE 2X2 2PKG|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.75||| A6403|EAP|0272||Medicare|MEDICARE ACUTE|||||15.25||| A6403|EAP|0272||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|15.25||||||| A6403|EAP|0272||Medicaid|MEDICAID|15.25||||||| A6405|EAP|0272|STRIP, NUGAUZE PACK 1/4 X|Blue Cross PPO Specialty|BCBSTX PPO|||||60.25||| A7000|EAP|0271||UTMB|UTMB CORRECTIONAL MANAGED CARE|||||31.25||| A7000|EAP|0271||United Healthcare|UNITED HEALTHCARE|||||31.25||| A7520|EAP|0274|TUBE TRACH UNCUFFED 3.0 D|Medicaid|MEDICAID|28.75||||||| A7521|EAP|0274|TUBE TRACH CUFFED 7.5 DIS|Humana Medicare Advantage|HUMANA MA|49.75||||49.75||| A7521|EAP|0274|TUBE TRACH CUFFED 7.0 DIS|Humana Medicare Advantage|HUMANA MA|0.42||||0.42||| A7521|EAP|0274|TUBE TRACH CUFFED 7.0 DIS|Brinson Benefits|THE HEALTH PLAN SMITH CO|0.42||||0.42||| A7521|EAP|0274|TUBE TRACH CUFFED 6.5 DIS|Cigna|CIGNA|||||0.38||| A7521|EAP|0274|TUBE TRACH CUFFED 7.5 DIS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|49.75||||49.75||| A7521|EAP|0274|TUBE TRACH CUFFED 7.0 DIS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.42||||0.42||| A7521|EAP|0274|TUBE TRACH CUFFED 7.5 DIS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.42||||49.75||| A7521|EAP|0274|TUBE TRACH CUFFED 7.0 DIS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.38||||0.42||| A7521|EAP|0274|TUBE TRACH CUFFED 7.5 DIS|Aenta Medicare Advantage|AETNA MEDICARE MA|49.75||||49.75||| A7521|EAP|0274|TUBE TRACH CUFFED 7.0 DIS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.42||||0.42||| 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|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||49.75||| A7521|EAP|0274|TUBE TRACH CUFFED 7.0 DIS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.42||| A7521|EAP|0274|TUBE TRACH CUFFED 7.5 DIS|Blue Cross HMO Specialty|BCBSTX HMO|0.42||||49.75||| A7521|EAP|0274|TUBE TRACH CUFFED 7.0 DIS|Blue Cross HMO Specialty|BCBSTX HMO|0.42||||0.42||| A7521|EAP|0274|TUBE TRACH CUFFED 7.0 DIS|Aetna|AETNA OTHER|||||0.42||| A7521|EAP|0274|TUBE TRACH CUFFED 7.0 DIS|Aetna|AETNA PPO|0.42||||0.42||| A7521|EAP|0274|TUBE TRACH CUFFED 7.5 DIS|Blue Cross PPO Specialty|BCBSTX PPO|49.75||||49.75||| A7521|EAP|0274|TUBE TRACH CUFFED 7.0 DIS|Blue Cross PPO Specialty|BCBSTX PPO|0.42||||0.42||| A7521|EAP|0274|TUBE TRACH CUFFED 7.0 DIS|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.42||| A7521|EAP|0274|TUBE TRACH CUFFED 7.5 DIS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.42||||49.75||| A7521|EAP|0274|TUBE TRACH CUFFED 7.0 DIS|United Medicare Advantage|UHC MEDICARE GOLD MA|0.42||||0.42||| A7521|EAP|0274|TUBE TRACH CUFFED 7.5 DIS|United Medicare Advantage|UHC MEDICARE GOLD MA|49.75||||49.75||| A7521|EAP|0274|TUBE TRACH CUFFED 7.0 DIS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.42||||0.42||| A7521|EAP|0274|TUBE TRACH CUFFED 7.0 DIS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.42||||0.42||| A7521|EAP|0274|TUBE TRACH CUFFED 7.5 DIS|United Healthcare|UNITED HEALTHCARE OTHER|49.75||||49.75||| A7521|EAP|0274|TUBE TRACH CUFFED 7.5 DIS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|49.75||||0.42||| A7521|EAP|0274|TUBE TRACH CUFFED 7.5 DIS|United Healthcare|UNITED HEALTHCARE|49.75||||||| A7521|EAP|0274|TUBE TRACH CUFFED 7.5 DIS|United Healthcare|UNITED HEALTHCARE|0.42||||49.75||| A7521|EAP|0274|TUBE TRACH CUFFED 6.5 DIS|Blue Cross PPO Specialty|BCBSTX PPO|0.38||||0.38||| A7521|EAP|0274|TUBE TRACH CUFFED 7.0 DIS|United Healthcare|UNITED HEALTHCARE OTHER|0.42||||0.42||| A7521|EAP|0274|TUBE TRACH CUFFED 7.0 DIS|United Healthcare|UNITED HEALTHCARE|0.42||||0.42||| A7521|EAP|0274|TUBE TRACH CUFFED 7.0 DIS|United Healthcare|UMR UNITED MEDICAL RESOURCES|0.42||||||| A7521|EAP|0274|TUBE TRACH CUFFED 7.0 DIS|Veterans Affairs|VETERANS ADMINISTRATION|0.42||||||| A7521|EAP|0274|TUBE TRACH CUFFED 7.0 DIS|Workers Compensation|WORKERS COMPENSATION OTHER|||||0.42||| A7521|EAP|0274|TUBE TRACH CUFFED 7.0 DIS|NON CONTRACTED|COMMERCIAL OTHER 1|49.75||||0.42||| A7521|EAP|0274|TUBE TRACH CUFFED 7.5 DIS|Medicare|MEDICARE ACUTE|49.75||||49.75||| A7521|EAP|0274|TUBE TRACH CUFFED 7.0 DIS|Medicare|MEDICARE PART B ONLY IP|||||0.42||| A7521|EAP|0274|TUBE TRACH CUFFED 7.0 DIS|Medicare|MEDICARE ACUTE|0.42||||0.42||| A7521|EAP|0274|TUBE TRACH CUFFED 7.0 DIS|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|0.42||||||| A7521|EAP|0274|TUBE TRACH CUFFED 7.0 DIS|Aenta Medicare Advantage|AETNA MEDICARE MA|0.42||||0.42||| A7521|EAP|0274|TUBE TRACH CUFFED 7.0 DIS|Tricare|TRICARE EAST REGION|0.42||||0.42||| A7521|EAP|0274|TUBE TRACH CUFFED 6.0 DIS|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||34.25||| A7521|EAP|0274|TUBE TRACH CUFFED 7.5 DIS|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||49.75||| A7521|EAP|0274|TUBE TRACH CUFFED 7.0 DIS|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||0.42||| A7521|EAP|0274|TUBE TRACH CUFFED 7.5 DIS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|49.75||||49.75||| A7521|EAP|0274|TUBE TRACH CUFFED 7.5 DIS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.42||||49.75||| A7521|EAP|0274|TUBE TRACH CUFFED 7.5 DIS|Managed Medicare|BCBS MEDICARE PPO MA|||||49.75||| A7521|EAP|0274|TUBE TRACH CUFFED 7.5 DIS|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||49.75||| A7521|EAP|0274|TUBE TRACH CUFFED 7.5 DIS|Managed Medicaid|MEDICAID SUPERIOR|49.75||||49.75||| A7521|EAP|0274|TUBE TRACH CUFFED 7.5 DIS|Managed Medicare|HEALTHSPRING MA|49.75||||||| A7521|EAP|0274|TUBE TRACH CUFFED 7.0 DIS|Managed Medicare|HEALTHSPRING MA|0.42||||||| A7521|EAP|0274|TUBE TRACH CUFFED 7.5 DIS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|49.75||||49.75||| A7521|EAP|0274|TUBE TRACH CUFFED 7.5 DIS|Managed Medicaid|MEDICAID AMERIGROUP|49.75||||49.75||| A7521|EAP|0274|TUBE TRACH CUFFED 7.0 DIS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.42||||0.42||| A7521|EAP|0274|TUBE TRACH CUFFED 7.0 DIS|Managed Medicaid|MEDICAID SUPERIOR|0.42||||0.42||| A7521|EAP|0274|TUBE TRACH CUFFED 7.0 DIS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.42||||0.42||| A7521|EAP|0274|TUBE TRACH CUFFED 7.0 DIS|Managed Medicaid|MEDICAID AMERIGROUP|0.42||||0.42||| A7521|EAP|0274|TUBE TRACH CUFFED 6.5 DIS|Managed Medicaid|MEDICAID SUPERIOR|0.38||||0.38||| A7521|EAP|0274|TUBE TRACH CUFFED 7.0 DIS|Medicaid|MEDICAID|0.38||||0.42||| A7521|EAP|0274|TUBE TRACH CUFFED 7.5 DIS|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||49.75||| A7521|EAP|0274|TUBE TRACH CUFFED 7.5 DIS|Medicaid|MEDICAID|49.75||||0.42||| A7521|EAP|0274|TUBE TRACH CUFFED 7.0 DIS|Medicaid|MEDICAID|0.42||||0.42||| 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 Medicare|HEALTHSPRING MA|||||648.25||| A9500|EAP|0255|DOSE SESTANIBI|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||648.25||| A9500|EAP|0255|DOSE SESTANIBI|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||648.25||| A9500|EAP|0255|DOSE SESTANIBI|NON CONTRACTED|COMMERCIAL OTHER 1|||||648.25||| A9500|EAP|0255|DOSE SESTANIBI|NON CONTRACTED|COMMERCIAL OTHER 2|||||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|UTMB|UTMB CORRECTIONAL MANAGED CARE|648.25||||||| A9500|EAP|0255|DOSE SESTANIBI|United Healthcare|UNITED HEALTHCARE|||||648.25||| A9500|EAP|0255|DOSE SESTANIBI|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||648.25||| A9500|EAP|0255|DOSE SESTANIBI|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||648.25||| A9500|EAP|0255|DOSE SESTANIBI|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||648.25||| A9500|EAP|0255|DOSE SESTANIBI|United Medicare Advantage|UHC MEDICARE GOLD MA|||||648.25||| A9500|EAP|0255|DOSE SESTANIBI|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||648.25||| A9500|EAP|0255|DOSE SESTANIBI|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||648.25||| A9500|EAP|0255|DOSE SESTANIBI|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||648.25||| A9500|EAP|0255|DOSE SESTANIBI|Aenta Medicare Advantage|AETNA MEDICARE MA|648.25||||648.25||| A9500|EAP|0255|DOSE SESTANIBI|Blue Cross PPO Specialty|BCBSTX PPO|||||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 OTHER|||||648.25||| A9500|EAP|0255|DOSE SESTANIBI|Humana Medicare Advantage|HUMANA MA|648.25||||648.25||| A9500|EAP|0255|DOSE SESTANIBI|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||648.25||| A9503|EAP|0255|BONE DOSE TC MDP|Humana Medicare Advantage|HUMANA MA|||||2.57||| A9503|EAP|0255|BONE DOSE TC MDP|Cigna|CIGNA|||||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|Blue Cross HMO Specialty|BCBSTX HMO|||||2.57||| A9503|EAP|0255|BONE DOSE TC MDP|United Medicare Advantage|UHC MEDICARE GOLD 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|Medicare|MEDICARE ACUTE|2.57||||2.57||| A9503|EAP|0255|BONE DOSE TC MDP|Tricare|TRICARE EAST REGION|||||2.57||| A9503|EAP|0255|BONE DOSE TC MDP|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||2.57||| A9503|EAP|0255|BONE DOSE TC MDP|Managed Medicare|HEALTHSPRING MA|||||2.57||| A9503|EAP|0255|BONE DOSE TC MDP|Medicaid|MEDICAID|||||2.57||| A9503|EAP|0255|BONE DOSE TC MDP|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||2.57||| A9516|EAP|0255|I-123 CAPSULE DIAGNOSTIC|NON CONTRACTED|COMMERCIAL OTHER 1|||||347.25||| A9516|EAP|0255|I-123 CAPSULE DIAGNOSTIC|Medicare|MEDICARE ACUTE|||||347.25||| A9516|EAP|0255|I-123 CAPSULE DIAGNOSTIC|United Healthcare|UNITED HEALTHCARE|||||347.25||| A9516|EAP|0255|I-123 CAPSULE DIAGNOSTIC|United Medicare Advantage|UHC MEDICARE GOLD MA|||||347.25||| A9516|EAP|0255|I-123 CAPSULE DIAGNOSTIC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||347.25||| A9516|EAP|0255|I-123 CAPSULE DIAGNOSTIC|Blue Cross PPO Specialty|BCBSTX PPO|||||347.25||| A9516|EAP|0255|I-123 CAPSULE DIAGNOSTIC|Humana Medicare Advantage|HUMANA MA|||||347.25||| A9537|EAP|0255|TC CHOLETEC|Cigna|CIGNA|||||3.79||| A9537|EAP|0255|TC CHOLETEC|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||3.79||| A9537|EAP|0255|TC CHOLETEC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||3.79||| A9537|EAP|0255|TC CHOLETEC|Blue Cross HMO Specialty|BCBSTX HMO|||||3.79||| A9537|EAP|0255|TC CHOLETEC|Aetna|AETNA OTHER|||||3.79||| A9537|EAP|0255|TC CHOLETEC|Blue Cross PPO Specialty|BCBSTX PPO|||||3.79||| A9537|EAP|0255|TC CHOLETEC|United Medicare Advantage|UHC MEDICARE GOLD MA|||||3.79||| A9537|EAP|0255|TC CHOLETEC|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||3.79||| A9537|EAP|0255|TC CHOLETEC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||3.79||| A9537|EAP|0255|TC CHOLETEC|Managed Medicaid|MEDICAID SUPERIOR|||||3.79||| A9537|EAP|0255|TC CHOLETEC|Managed Medicaid|MEDICAID AMERIGROUP|||||3.79||| A9537|EAP|0255|TC CHOLETEC|NON CONTRACTED|COMMERCIAL OTHER 1|||||3.79||| A9537|EAP|0255|TC CHOLETEC|Medicare|MEDICARE ACUTE|3.79||||3.79||| A9540|EAP|0255|TECHNETIUM 99M MACRO 4MC|Medicare|MEDICARE ACUTE|||||3.40||| A9540|EAP|0255|TECHNETIUM 99M MACRO 4MC|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|3.40||||||| A9540|EAP|0255|TECHNETIUM 99M MACRO 4MC|Aetna|AETNA PPO|||||3.40||| A9540|EAP|0255|TECHNETIUM 99M MACRO 4MC|Humana Medicare Advantage|HUMANA MA|||||3.40||| A9558|EAP|0255|XENON XE-133|Humana Medicare Advantage|HUMANA MA|||||291.25||| A9558|EAP|0255|XENON XE-133|Aetna|AETNA PPO|||||291.25||| A9558|EAP|0255|XENON XE-133|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|291.25||||||| A9558|EAP|0255|XENON XE-133|Medicare|MEDICARE ACUTE|||||291.25||| A9562|EAP|0341|DOSE MAG 3|Blue Cross PPO Specialty|BCBSTX PPO|||||7.82||| A9576|EAP|0255|PROHANCE 20 ML VL NDC 027|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||9.24||| A9576|EAP|0255|PROHANCE 20 ML VL NDC 027|Managed Medicaid|MEDICAID AMERIGROUP|||||9.24||| A9576|EAP|0255|PROHANCE 15 ML NDC 0279-1|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||9.87||| A9576|EAP|0255|PROHANCE 20 ML VL NDC 027|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||9.24||| A9576|EAP|0255|PROHANCE 15 ML NDC 0279-1|Managed Medicare|HEALTHSPRING MA|9.87||||||| A9576|EAP|0255|PROHANCE 20 ML VL NDC 027|Medicaid|MEDICAID|9.24||||||| A9576|EAP|0255|PROHANCE 15 ML NDC 0279-1|NON CONTRACTED|COMMERCIAL OTHER 1|||||9.87||| A9576|EAP|0255|PROHANCE 15 ML NDC 0279-1|Medicare|MEDICARE ACUTE|9.87||||9.87||| A9576|EAP|0255|PROHANCE 20 ML VL NDC 027|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||9.24||| A9576|EAP|0255|PROHANCE 20 ML VL NDC 027|United Healthcare|UNITED HEALTHCARE|||||9.24||| A9576|EAP|0255|PROHANCE 20 ML VL NDC 027|United Healthcare|TML GROUP BENEFITS|||||9.24||| A9576|EAP|0255|PROHANCE 15 ML NDC 0279-1|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||9.87||| A9576|EAP|0255|PROHANCE 15 ML NDC 0279-1|United Medicare Advantage|UHC MEDICARE GOLD MA|||||9.87||| A9576|EAP|0255|PROHANCE 20 ML VL NDC 027|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||9.24||| A9576|EAP|0255|PROHANCE 15 ML NDC 0279-1|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||9.87||| A9576|EAP|0255|PROHANCE 20 ML VL NDC 027|Medicare|MEDICARE ACUTE|9.24||||9.24||| A9576|EAP|0255|PROHANCE 20 ML VL NDC 027|United Medicare Advantage|UHC MEDICARE GOLD MA|||||9.24||| A9576|EAP|0255|PROHANCE 20 ML VL NDC 027|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9.24||||9.24||| A9576|EAP|0255|PROHANCE 15 ML NDC 0279-1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|9.87||||9.87||| A9576|EAP|0255|PROHANCE 20 ML VL NDC 027|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||9.24||| A9576|EAP|0255|PROHANCE 20 ML VL NDC 027|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||9.24||| A9576|EAP|0255|PROHANCE 20 ML VL NDC 027|Access Direct Platinum|HEALTHFIRST TPA UMR|||||9.24||| A9576|EAP|0255|PROHANCE 20 ML VL NDC 027|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||9.24||| A9576|EAP|0255|PROHANCE 15 ML NDC 0279-1|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||9.87||| A9576|EAP|0255|PROHANCE 20 ML VL NDC 027|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||9.24||| A9576|EAP|0255|PROHANCE 20 ML VL NDC 027|Aenta Medicare Advantage|AETNA MEDICARE MA|||||9.24||| A9576|EAP|0255|PROHANCE 15 ML NDC 0279-1|Blue Cross HMO Specialty|BCBSTX HMO|||||9.87||| A9576|EAP|0255|PROHANCE 20 ML VL NDC 027|Blue Cross HMO Specialty|BCBSTX HMO|||||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 20 ML VL NDC 027|Humana Medicare Advantage|HUMANA MA|||||9.24||| 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|Cigna|CIGNA|||||9.24||| A9576|EAP|0255|PROHANCE 15 ML NDC 0279-1|Cigna|CIGNA|||||9.87||| A9579|EAP|0636|MRI CONTRAST GADOLINIUM V|Humana Medicare Advantage|HUMANA MA|||||5.50||| A9579|EAP|0636|MRI CONTRAST GADOLINIUM V|Medicare|MEDICARE ACUTE|5.50||||||| A9579|EAP|0636|MRI CONTRAST GADOLINIUM V|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||5.50||| C1713|EAP|0278|SUTURE IMPLANTABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.55||||0.39||| C1713|EAP|0278|NONLOCKING CORTICAL SCREW|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|469.25||||0.39||| C1713|EAP|0278|LOCKING CORTICAL SCREW 3.|Managed Medicaid|MEDICAID AMERIGROUP|||||210.25||| C1713|EAP|0278|FLEXIBLE PASSING PIN 13.5|Managed Medicaid|MEDICAID AMERIGROUP|||||6.51||| C1713|EAP|0278|CORTICAL SCREW 3.5X12MM|Managed Medicaid|MEDICAID AMERIGROUP|||||141.25||| C1713|EAP|0278|2.3 THREADED LOCKING SCRE|Managed Medicaid|MEDICAID AMERIGROUP|||||161.50||| C1713|EAP|0278|PERIARTL/CORTICAL SCREW 3|Medicaid|MEDICAID|||||62.75||| C1713|EAP|0278|PERI/CORTICAL SCREW 3.5 X|Medicaid|MEDICAID|||||0.61||| C1713|EAP|0278|LOCKING SCREW 2.7X16MM|Medicaid|MEDICAID|||||161.75||| C1713|EAP|0278|LOCKING SCREW 2.7X14 LONG|Medicaid|MEDICAID|||||161.75||| C1713|EAP|0278|LOCKING SCREW 2.7MMX18MM|Medicaid|MEDICAID|||||161.75||| C1713|EAP|0272||Medicare|MEDICARE ACUTE|||||141.25||| C1713|EAP|0272||Medicare|MEDICARE ACUTE|||||210.25||| C1713|EAP|0278|TENDON ANCHORS 8|Medicare|MEDICARE ACUTE|149.75||||64.20||| C1713|EAP|0278|SUTURE IMPLANTABLE|Medicare|MEDICARE ACUTE|2.55||||64.20||| C1713|EAP|0278|SCREW OR ANCHOR IMPLANTAB|Medicare|MEDICARE ACUTE|161.75||||133.33||| C1713|EAP|0278|SCREW 3.5 X 14MM|Medicare|MEDICARE ACUTE|161.75||||148.25||| C1713|EAP|0278|SCREW 3.5 X 14MM|Medicare|MEDICARE ACUTE|148.25||||64.20||| C1713|EAP|0278|NCB SCREW S/TAP 4.0 X 34|Medicare|MEDICARE ACUTE|199.75||||64.20||| C1713|EAP|0278|NCB SCREW S/TAP 4.0 X 28|Medicare|MEDICARE ACUTE|199.75||||64.20||| C1713|EAP|0278|NCB SCREW S/TAP 4.0 X 28|Medicare|MEDICARE ACUTE|161.75||||199.75||| C1713|EAP|0278|LOCKING CORTICAL SCREW 3.|Medicare|MEDICARE ACUTE|210.25||||210.25||| C1713|EAP|0278|CORTICAL SCREW 3.5MM X 16|Medicare|MEDICARE ACUTE|1,043.75||||141.25||| C1713|EAP|0278|BONE ANCHORS 3 W ARTHRO D|Medicare|MEDICARE ACUTE|469.25||||64.20||| C1713|EAP|0278|2.8MM Q-FIX IMPLANT|Medicare|MEDICARE ACUTE|210.75||||508.20||| C1713|EAP|0278|2.8 DISPOSABLE Q-FIX IMPL|Medicare|MEDICARE ACUTE|2.73||||389.40||| C1713|EAP|0278|2.3MM/18MM THREADED LOCKI|Medicare|MEDICARE ACUTE|213.25||||1.49||| C1713|EAP|0278|2.3MM THREADED LOCKING SC|Medicare|MEDICARE ACUTE|107.50||||161.50||| C1713|EAP|0278|2.3 X 22MM LOCK PEG (ACUM|Medicare|MEDICARE ACUTE|211.75||||211.75||| C1713|EAP|0278|2.3 THREADED LOCKING SCRE|Medicare|MEDICARE ACUTE|161.50||||161.50||| C1713|EAP|0278|NCB CANCELLOUS SCREW 5.0|Medicare|MEDICARE ACUTE|259.75||||64.20||| C1713|EAP|0278|NCB SCREW S/TAP 4.0 X 40|Medicare|MEDICARE ACUTE|199.75||||64.20||| C1713|EAP|0278|NONLOCKING CORTICAL SCREW|Tricare|TRICARE EAST REGION|2.55||||0.39||| C1713|EAP|0278|LOCKING SCREW TI 3.5 X 20|Tricare|TRICARE EAST REGION|2.55||||156.50||| C1713|EAP|0278|SUTURE IMPLANTABLE|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.55||||||| C1713|EAP|0278|LAG SCREW 10.5DIA/105 LGT|UTMB|UTMB CORRECTIONAL MANAGED CARE|1,043.75||||||| C1713|EAP|0278|SCREW OR ANCHOR IMPLANTAB|United Medicare Advantage|AARP UHC WEST COMPLETE MA|2.55||||1.00||| C1713|EAP|0278|LOCKING SCREW 2.7X16MM|United Medicare Advantage|AARP UHC WEST COMPLETE MA|2.55||||161.75||| C1713|EAP|0278|DE PUY CEMENT INJ. KIT|United Medicare Advantage|UHC MEDICARE GOLD MA|469.25||||||| C1713|EAP|0278|DE PUY CEMENT INJ. KIT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|469.25||||||| C1713|EAP|0278|LOCKING SCREW 2.7X14 LONG|United Medicare Advantage|AARP UHC WEST COMPLETE MA|469.25||||161.75||| C1713|EAP|0278|SCREW OR ANCHOR IMPLANTAB|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1.38||||||| C1713|EAP|0278|DE PUY CEMENT INJ. KIT|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|469.25||||||| C1713|EAP|0278|SCREW OR ANCHOR IMPLANTAB|Workers Compensation|WORKERS COMPENSATION OTHER|7.94||||||| C1713|EAP|0278|2.8 DISPOSABLE Q-FIX IMPL|Workers Compensation|WORKERS COMPENSATION OTHER|389.40||||||| C1713|EAP|0278|SMARTSTITCH SUTURE|Blue Cross PPO Specialty|BCBSTX PPO|2.55||||1,832.25||| C1713|EAP|0278|SUTURE IMPLANTABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.55||||127.50||| C1713|EAP|0272||Blue Cross PPO Specialty|BCBSTX PPO|||||389.40||| C1713|EAP|0278|SCREW OR ANCHOR IMPLANTAB|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|469.25||||127.50||| C1713|EAP|0278|SUTURE IMPLANTABLE|Aenta Medicare Advantage|AETNA MEDICARE MA|2.55||||||| C1713|EAP|0278|SCREW OR ANCHOR IMPLANTAB|Aenta Medicare Advantage|AETNA MEDICARE MA|22.25||||||| C1713|EAP|0278|2.8 DISPOSABLE Q-FIX IMPL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||389.40||| C1713|EAP|0278|SCREW OR ANCHOR IMPLANTAB|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.75||||127.50||| C1713|EAP|0278|2.8MM Q-FIX IMPLANT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||508.20||| C1713|EAP|0278|BONE ANCHORS 3 W ARTHRO D|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||30.00||| C1713|EAP|0278|44MM/4.5 MM SELF TAPPING|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|2.55||||0.55||| C1713|EAP|0278|TENDON ANCHORS 8|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||30.00||| C1713|EAP|0272||Blue Cross HMO Specialty|BCBSTX HMO|||||508.20||| C1713|EAP|0272||Blue Cross HMO Specialty|BCBSTX HMO|||||389.40||| C1713|EAP|0278|2.8MM Q-FIX IMPLANT|Workers Compensation|WORKERS COMPENSATION OTHER|508.20||||||| C1713|EAP|0278|SCREW OR ANCHOR IMPLANTAB|Blue Cross HMO Specialty|BCBSTX HMO|2.55||||86.25||| C1713|EAP|0278|LOCKING CORTICAL SCREW 3.|Blue Cross HMO Specialty|BCBSTX HMO|2.55||||2.12||| C1713|EAP|0278|3.5 X 16MM SCREW|Blue Cross HMO Specialty|BCBSTX HMO|2.55||||213.25||| C1713|EAP|0278|2.8MM Q-FIX IMPLANT|Blue Cross HMO Specialty|BCBSTX HMO|2.55||||508.20||| C1713|EAP|0278|LOCKING SCREW 3.5X14MM W/|United Medicare Advantage|AARP UHC WEST COMPLETE MA|2.55||||48.50||| C1713|EAP|0278|2.8 DISPOSABLE Q-FIX IMPL|Blue Cross HMO Specialty|BCBSTX HMO|2.55||||389.40||| C1713|EAP|0278|2.3MM THREADED LOCKING SC|Blue Cross HMO Specialty|BCBSTX HMO|27.28||||161.50||| C1713|EAP|0278|2.3MM 26MM THREADED LOCKI|Blue Cross HMO Specialty|BCBSTX HMO|469.25||||107.50||| C1713|EAP|0278|SMARTSTITCH SUTURE|Blue Cross HMO Specialty|BCBSTX HMO|2.55||||1,832.25||| C1713|EAP|0278|CANNULATED SCREW 2.5X.50M|Tricare|TRICARE EAST REGION|469.25||||2.14||| C1713|EAP|0272||Blue Cross PPO Specialty|BCBSTX PPO|||||508.20||| C1713|EAP|0278|LOCKING SCREW 2.7X16MM|Blue Cross PPO Specialty|BCBSTX PPO|2.55||||161.75||| C1713|EAP|0278|SCREW OR ANCHOR IMPLANTAB|Medicare|MEDICARE ACUTE|137.50||||64.20||| C1713|EAP|0278|LOCKING CORTICAL SCREW 3.|Blue Cross PPO Specialty|BCBSTX PPO|2.55||||210.25||| C1713|EAP|0278|3.5 X 16MM SCREW|Blue Cross PPO Specialty|BCBSTX PPO|2.55||||213.25||| C1713|EAP|0278|THREADED LOCKING SCREW 2.|Blue Cross PPO Specialty|BCBSTX PPO|2.55||||153.50||| C1713|EAP|0278|2.3MM 26MM THREADED LOCKI|Blue Cross PPO Specialty|BCBSTX PPO|469.25||||107.50||| C1713|EAP|0278|LOCKING SCREW 3.5MMX1MMW/|Blue Cross PPO Specialty|BCBSTX PPO|2.55||||149.75||| C1713|EAP|0278|SCREW 3.5 X 14MM|Blue Cross PPO Specialty|BCBSTX PPO|2.55||||148.25||| C1713|EAP|0278|3.5 X 16MM SCREW|Medicare|MEDICARE ACUTE|141.25||||213.25||| C1713|EAP|0278|LOCKING SCREW 2.7MMX18MM|Blue Cross PPO Specialty|BCBSTX PPO|2.55||||161.75||| C1713|EAP|0278|2.3 THREADED LOCKING SCRE|Blue Cross PPO Specialty|BCBSTX PPO|2.73||||161.50||| C1713|EAP|0272|NCB SCREW 4.0 X 46|Humana Medicare Advantage|HUMANA MA|1.76||||||| C1713|EAP|0278|TENDON ANCHORS 8|Humana Medicare Advantage|HUMANA MA|2.55||||64.20||| C1713|EAP|0278|NCB CANCELLOUS SCREW 4.5M|Medicare|MEDICARE ACUTE|2.12||||218.50||| C1713|EAP|0278|SMARTSTITCH SUTURE|Humana Medicare Advantage|HUMANA MA|2.55||||1,832.25||| C1713|EAP|0278|SCREW 3.5 X 14MM|Humana Medicare Advantage|HUMANA MA|2.55||||148.25||| C1713|EAP|0278|LOCKING CORTICAL SCREW 3.|Humana Medicare Advantage|HUMANA MA|101.15||||210.25||| C1713|EAP|0278|CORTICAL SCREW 3.5X12MM|Humana Medicare Advantage|HUMANA MA|199.75||||141.25||| C1713|EAP|0278|PERIARTL/CORTICAL SCREW 3|Medicare|MEDICARE ACUTE|62.75||||64.20||| C1713|EAP|0278|BONE ANCHORS 3 W ARTHRO D|Humana Medicare Advantage|HUMANA MA|259.75||||64.20||| C1713|EAP|0278|3.5 X 16MM SCREW|Humana Medicare Advantage|HUMANA MA|210.25||||213.25||| C1713|EAP|0278|2.8 DISPOSABLE Q-FIX IMPL|Humana Medicare Advantage|HUMANA MA|469.25||||389.40||| C1713|EAP|0278|2.3MM/18MM THREADED LOCKI|Humana Medicare Advantage|HUMANA MA|1.49||||1.49||| C1713|EAP|0278|2.3MM THREADED LOCKING SC|Humana Medicare Advantage|HUMANA MA|161.50||||161.50||| C1713|EAP|0278|2.3MM 26MM THREADED LOCKI|Humana Medicare Advantage|HUMANA MA|161.50||||107.50||| C1713|EAP|0278|2.3 THREADED LOCKING SCRE|Humana Medicare Advantage|HUMANA MA|27.29||||161.50||| C1713|EAP|0278|2.8MM Q-FIX IMPLANT|Humana Medicare Advantage|HUMANA MA|1,043.75||||508.20||| C1713|EAP|0272||Medicare|MEDICARE ACUTE|||||161.50||| C1713|EAP|0278|LOCKING SCREW 3.5X14MM W/|Medicaid|MEDICAID|||||48.50||| C1713|EAP|0278|DE PUY CEMENT INJ. KIT|Humana Medicare Advantage|HUMANA MA|148.25||||469.25||| C1713|EAP|0278|SUTURE IMPLANTABLE|Humana Medicare Advantage|HUMANA MA|2.55||||2.55||| C1713|EAP|0278|FLEXIBLE PASSING PIN 13.5|Blue Cross PPO Specialty|BCBSTX PPO|2.55||||2.69||| C1713|EAP|0278|SCREW OR ANCHOR IMPLANTAB|Blue Cross PPO Specialty|BCBSTX PPO|2.55||||95.83||| C1713|EAP|0278|2.3MM 26MM THREADED LOCKI|Managed Medicaid|MEDICAID AMERIGROUP|||||107.50||| C1713|EAP|0278|CORTICAL SCREW 3.5MM X 16|Blue Cross PPO Specialty|BCBSTX PPO|2.55||||141.25||| C1713|EAP|0278|LOCKING SCREW 3.5/16MM W2|Blue Cross PPO Specialty|BCBSTX PPO|2.55||||149.75||| C1713|EAP|0278|CANNULATED SCREW 1/2 4.0|Blue Cross PPO Specialty|BCBSTX PPO|2.55||||244.25||| C1713|EAP|0278|SCREW OR ANCHOR IMPLANTAB|Cigna|CIGNA|||||0.25||| C1713|EAP|0278|2.8MM Q-FIX IMPLANT|Cigna|CIGNA|||||508.20||| C1713|EAP|0278|2.8 DISPOSABLE Q-FIX IMPL|Cigna|CIGNA|||||389.40||| C1713|EAP|0278|SMARTSTITCH SUTURE|Cigna|CIGNA|||||1,832.25||| C1713|EAP|0278|DE PUY CEMENT INJ. KIT|Cigna|CIGNA|469.25||||||| C1713|EAP|0278|2.8MM Q-FIX IMPLANT|Blue Cross PPO Specialty|BCBSTX PPO|214.25||||508.20||| C1713|EAP|0278|PERI/CORTICAL SCREW 3.5 X|Blue Cross PPO Specialty|BCBSTX PPO|2.55||||0.61||| C1713|EAP|0278|LOCKING SCREW 2.7X14 LONG|Blue Cross PPO Specialty|BCBSTX PPO|2.55||||161.75||| C1713|EAP|0278|2.8 DISPOSABLE Q-FIX IMPL|Blue Cross PPO Specialty|BCBSTX PPO|57.50||||389.40||| C1713|EAP|0278|2.3MM/18MM THREADED LOCKI|Blue Cross PPO Specialty|BCBSTX PPO|259.75||||1.49||| C1713|EAP|0278|DE PUY CEMENT INJ. KIT|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|469.25||||||| C1713|EAP|0278|2.3MM THREADED LOCKING SC|Blue Cross PPO Specialty|BCBSTX PPO|259.75||||161.50||| C1713|EAP|0278|LOCKING SCREW 2.7MMX20MML|Blue Cross PPO Specialty|BCBSTX PPO|2.55||||161.75||| C1763|EAP|0278|ARTHRO BIOINDCTIVE IMPL 1|Humana Medicare Advantage|HUMANA MA|||||128.40||| C1763|EAP|0278|ARTHRO BIOINDCTIVE IMPL 1|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||60.00||| C1763|EAP|0278|ARTHRO BIOINDCTIVE IMPL 1|Medicare|MEDICARE ACUTE|||||128.40||| C1769|EAP|0272|K-WIRES|Managed Medicaid|MEDICAID SUPERIOR|202.75||||0.79||| C1769|EAP|0272|K-WIRES|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.79||| C1769|EAP|0272|.054 WIRES|Managed Medicaid|MEDICAID AMERIGROUP|||||50.50||| C1769|EAP|0272|K. WIRE 1.6MM DIA/1.50MM|Medicaid|MEDICAID|0.79||||98.25||| C1769|EAP|0272|TRUMATCH PIN GUIDE 2.5 FM|Medicare|MEDICARE ACUTE|7.92||||46.25||| C1769|EAP|0272|K. WIRE 1.6MM DIA/1.50MM|Medicare|MEDICARE ACUTE|98.25||||46.25||| C1769|EAP|0272|.054 WIRES|Medicare|MEDICARE ACUTE|50.50||||50.50||| C1769|EAP|0272|KIRSCHNER WIRE NCB|Medicare|MEDICARE ACUTE|53.25||||46.25||| C1769|EAP|0272|K-WIRE 1.25MM DIA/150MM (|Tricare|TRICARE EAST REGION|7.92||||98.25||| C1769|EAP|0272|BALL TIP GUIDE WIRE 3.0MM|UTMB|UTMB CORRECTIONAL MANAGED CARE|202.75||||||| C1769|EAP|0272|BALL TIP GUIDE WIRE 3.0MM|United Medicare Advantage|UHC MEDICARE GOLD MA|202.75||||||| C1769|EAP|0272|K-WIRE 2.0 MM,280MM LENGT|United Medicare Advantage|AARP UHC WEST COMPLETE MA|7.92||||0.45||| C1769|EAP|0272|KIRSCHNER WIRE (ZIMMER) 2|Medicare|MEDICARE ACUTE|202.75||||46.25||| C1769|EAP|0272|TRUMATCH PIN GUIDE 2.5 FM|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|7.92||||||| C1769|EAP|0272|BALL TIP GUIDE WIRE 3.0MM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|202.75||||||| C1769|EAP|0272|TRUMATCH PIN GUIDE 2.5 FM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|7.92||||||| C1769|EAP|0272|K-WIRES|United Healthcare|UNITED HEALTHCARE|||||0.79||| C1769|EAP|0272|K-WIRES|United Healthcare|UNITED HEALTHCARE OTHER|||||0.79||| C1769|EAP|0272|KIRSCHNER WIRE (ZIMMER) 2|Aenta Medicare Advantage|AETNA MEDICARE MA|46.25||||||| C1769|EAP|0272|BALL TIP GUIDE WIRE 3.0MM|Aenta Medicare Advantage|AETNA MEDICARE MA|202.75||||||| C1769|EAP|0272|K-WIRES 2.0X150 TROCAR PT|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||82.25||| C1769|EAP|0272|K-WIRES|Blue Cross HMO Specialty|BCBSTX HMO|7.92||||0.79||| C1769|EAP|0272|.054 WIRES|Blue Cross PPO Specialty|BCBSTX PPO|0.79||||50.50||| C1769|EAP|0272|TRUMATCH PIN GUIDE 2.5 FM|Blue Cross PPO Specialty|BCBSTX PPO|7.92||||0.79||| C1769|EAP|0272|LPS FLEX PIN GUIDES (FEMU|Blue Cross PPO Specialty|BCBSTX PPO|14.52||||0.79||| C1769|EAP|0272|K-WIRES|Blue Cross PPO Specialty|BCBSTX PPO|53.25||||0.79||| C1769|EAP|0272|TRUMATCH PIN GUIDE 2.5 FM|Humana Medicare Advantage|HUMANA MA|7.92||||50.50||| C1769|EAP|0272|.054 WIRES|Humana Medicare Advantage|HUMANA MA|50.50||||50.50||| C1769|EAP|0272|K-WIRE 2.0 MM,280MM LENGT|Humana Medicare Advantage|HUMANA MA|0.45||||50.50||| C1776|EAP|0272|TIBIAL BASE ROTATING PLAT|Humana Medicare Advantage|HUMANA MA|20.02||||||| C1776|EAP|0272||Humana Medicare Advantage|HUMANA MA|5.18||||||| C1776|EAP|0278|TIB INS ROTATING POSTERIO|Humana Medicare Advantage|HUMANA MA|12.54||||2,915.50||| C1776|EAP|0278|THREADED PIN 3.0MMX305MM|Humana Medicare Advantage|HUMANA MA|2.21||||2,915.50||| C1776|EAP|0278|THR TOTAL HIP REPLACEMENT|Humana Medicare Advantage|HUMANA MA|56.10||||2,915.50||| C1776|EAP|0278|SMART SET GHV GENT BONE C|Humana Medicare Advantage|HUMANA MA|5.18||||2,915.50||| C1776|EAP|0278|REVERSE SHOULDER-GLENOSPH|Humana Medicare Advantage|HUMANA MA|2,938.50||||2,915.50||| C1776|EAP|0278|REVERSE SHOULDER SYSTEM H|Humana Medicare Advantage|HUMANA MA|95.15||||2,915.50||| C1776|EAP|0278|POSTERIOR STAB.FEMORAL CO|Humana Medicare Advantage|HUMANA MA|786.25||||2,915.50||| C1776|EAP|0278|LPS-MOB ARTICULAR SURFACE|Humana Medicare Advantage|HUMANA MA|1,528.80||||15.63||| C1776|EAP|0278|FLUTED STEM TIBIAL COMPON|Humana Medicare Advantage|HUMANA MA|12.14||||2,312.50||| C1776|EAP|0278|DISTAL RADIUS PLT NARROW/|Humana Medicare Advantage|HUMANA MA|2,312.50||||1,761.75||| C1776|EAP|0278|BONE CEMENT ANTIBOTIC SIM|Humana Medicare Advantage|HUMANA MA|1,116.25||||790.75||| C1776|EAP|0278|ALL POLY PATELLA SIZE 35|Humana Medicare Advantage|HUMANA MA|417.75||||1,116.25||| C1776|EAP|0278|STANDARD DISTAL RADIUS PL|Humana Medicare Advantage|HUMANA MA|1,759.75||||2,915.50||| C1776|EAP|0278|PATELLA (ZIMMER)|Blue Cross PPO Specialty|BCBSTX PPO|1,115.75||||4,627.50||| C1776|EAP|0278|SMART SET GHV GENT BONE C|Blue Cross PPO Specialty|BCBSTX PPO|5.18||||4,627.50||| C1776|EAP|0278|POSTERIOR STAB.FEMORAL CO|Blue Cross PPO Specialty|BCBSTX PPO|2,915.50||||4,627.50||| C1776|EAP|0278|PATELLA MEDIALIZED DOME 4|Blue Cross PPO Specialty|BCBSTX PPO|786.25||||4,627.50||| C1776|EAP|0278|SMART SET GHV GENT BONE C|Cigna|CIGNA|5.18||||||| C1776|EAP|0278|JOINT DEVICE IMPLANTABLE|Cigna|CIGNA|24.49||||||| C1776|EAP|0278|CANNULA DISP/6.0MM X 75MM|Cigna|CIGNA|||||0.10||| C1776|EAP|0278|MAGNUM 2 IMPLANT|Blue Cross PPO Specialty|BCBSTX PPO|15.63||||4,627.50||| C1776|EAP|0278|JOINT DEVICE IMPLANTABLE|Blue Cross PPO Specialty|BCBSTX PPO|326.50||||28.10||| C1776|EAP|0278|JOINT DEVICE IMPLANTABLE|Blue Cross PPO Specialty|BCBSTX OTHER|||||4,013.30||| C1776|EAP|0278|CANNULA DISP/6.0MM X 75MM|Blue Cross PPO Specialty|BCBSTX PPO|790.75||||0.10||| C1776|EAP|0278|BONE CEMENT ANTIBOTIC SIM|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|790.75||||||| C1776|EAP|0278|ALL POLY PATELLA SIZE 35|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1,116.25||||||| C1776|EAP|0278|JOINT DEVICE IMPLANTABLE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|27.70||||||| C1776|EAP|0270||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,116.25||||||| C1776|EAP|0272||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||82.25||| C1776|EAP|0278|THREADED PIN 3.0MMX305MM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.21||||0.10||| C1776|EAP|0278|HUMERAL STEM SPACER 9MM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|12.14||||0.10||| C1776|EAP|0278|REVERSE SHOULDER-GLENOSPH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2,938.50||||0.10||| C1776|EAP|0278|CANNULA DISP/6.0MM X 75MM|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|790.75||||0.10||| C1776|EAP|0278|JOINT DEVICE IMPLANTABLE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|25.49||||0.10||| C1776|EAP|0278|RETENTIVE LINER + OMM OFF|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,906.25||||0.10||| C1776|EAP|0278|PATELLA (ZIMMER)|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,115.75||||0.10||| C1776|EAP|0272||Aenta Medicare Advantage|AETNA MEDICARE MA|5.18||||||| C1776|EAP|0278|THR TOTAL HIP REPLACEMENT|Aenta Medicare Advantage|AETNA MEDICARE MA|56.10||||||| C1776|EAP|0278|PATELLA MEDIALIZED DOME 4|Aenta Medicare Advantage|AETNA MEDICARE MA|786.25||||||| C1776|EAP|0278|JOINT DEVICE IMPLANTABLE|Aenta Medicare Advantage|AETNA MEDICARE MA|24.40||||||| C1776|EAP|0278|BONE CEMENT ANTIBOTIC SIM|Aenta Medicare Advantage|AETNA MEDICARE MA|790.75||||||| C1776|EAP|0272|DRILL BIT & STEINMAN PIN|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|330.75||||||| C1776|EAP|0272|ROTATING STABLIZED TIBIAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1,626.50||||||| C1776|EAP|0272|POSTERIOR STABILIZED FEMU|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|5,109.25||||||| C1776|EAP|0272||Access Direct Platinum|HEALTHFIRST TPA UTH UMR|5.18||||||| C1776|EAP|0278|OVAL DOME PATELLA 3-PEG 3|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|815.50||||||| C1776|EAP|0278|MAGNUM 2 IMPLANT|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||4,627.50||| C1776|EAP|0278|RETENTIVE LINER + OMM OFF|Blue Cross HMO Specialty|BCBSTX HMO|11.90||||1,906.25||| C1776|EAP|0278|MAGNUM 2 IMPLANT|Blue Cross HMO Specialty|BCBSTX HMO|11.90||||4,627.50||| C1776|EAP|0278|HUMERAL STEM SPACER 9MM|Blue Cross HMO Specialty|BCBSTX HMO|786.25||||12.14||| C1776|EAP|0278|CANNULA DISP/6.0MM X 75MM|Blue Cross HMO Specialty|BCBSTX HMO|786.25||||0.10||| C1776|EAP|0270|KNOTLESS FIXATION DEVICE|Blue Cross PPO Specialty|BCBSTX PPO|||||4,627.50||| C1776|EAP|0278|THR TOTAL HIP REPLACEMENT|United Medicare Advantage|AARP UHC WEST COMPLETE MA|56.10||||962.50||| C1776|EAP|0272||Blue Cross PPO Specialty|BCBSTX PPO|5.18||||0.10||| C1776|EAP|0278|TIBIAL INSERT ROTATING PL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|23.64||||3.00||| C1776|EAP|0278|THR TOTAL HIP REPLACEMENT|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|56.10||||0.10||| C1776|EAP|0278|SMART SET GHV GENT BONE C|United Medicare Advantage|UHC MEDICARE GOLD MA|5.18||||||| C1776|EAP|0278|SMART SET GHV GENT BONE C|United Medicare Advantage|AARP UHC WEST COMPLETE MA|5.18||||962.50||| C1776|EAP|0278|RETENTIVE LINER + OMM OFF|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,906.25||||3.00||| C1776|EAP|0278|PATELLA MEDICALIZED DOME|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|786.25||||3.00||| C1776|EAP|0278|JOINT DEVICE IMPLANTABLE|Blue Cross HMO Specialty|BCBSTX HMO|5.18||||47.25||| C1776|EAP|0278|CANNULA DISP/6.0MM X 75MM|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.10||| C1776|EAP|0278|JOINT DEVICE IMPLANTABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|21.10||||3.00||| C1776|EAP|0278|JOINT DEVICE IMPLANTABLE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|15.00||||962.50||| C1776|EAP|0278|BONE CEMENT ANTIBOTIC SIM|United Medicare Advantage|AARP UHC WEST COMPLETE MA|790.75||||962.50||| C1776|EAP|0278|ALL POLY PATELLA SIZE 35|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,116.25||||3.00||| C1776|EAP|0278|THR TOTAL HIP REPLACEMENT|United Medicare Advantage|UHC MEDICARE GOLD MA|56.10||||||| C1776|EAP|0278|REVERSE SHOULDER-GLENOSPH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2,938.50||||3.00||| C1776|EAP|0278|SMART SET GHV GENT BONE C|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|5.18||||3.00||| C1776|EAP|0278|BONE CEMENT ANTIBOTIC SIM|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|790.75||||3.00||| C1776|EAP|0278|METAL ALTERNATIVE FEMORAL|Aenta Medicare Advantage|AETNA MEDICARE MA|236.80||||||| C1776|EAP|0278|PATELLA MEDIALIZED DOME 4|United Medicare Advantage|AARP UHC WEST COMPLETE MA|786.25||||962.50||| C1776|EAP|0278|PERI/DISTAL LAT FIB LKG P|United Medicare Advantage|AARP UHC WEST COMPLETE MA|1,116.25||||962.50||| C1776|EAP|0278|FLUTED STEM TIBIAL COMPON|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2,312.50||||0.10||| C1776|EAP|0278|SMART SET GHV GENT BONE C|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|5.18||||0.10||| C1776|EAP|0278|FLUTED STEM TIBIAL COMPON|United Medicare Advantage|AARP UHC WEST COMPLETE MA|2,312.50||||962.50||| C1776|EAP|0278|CANNULA DISP/6.0MM X 75MM|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|786.25||||0.10||| C1776|EAP|0278|JOINT DEVICE IMPLANTABLE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|417.75||||3.00||| C1776|EAP|0278|CANNULA DISP/6.0MM X 75MM|United Healthcare|UNITED HEALTHCARE OTHER|||||0.10||| C1776|EAP|0278|FLUTED STEM MOBIL TIBIAL|Workers Compensation|WORKERS COMPENSATION OTHER|2,697.75||||||| C1776|EAP|0278|SMART SET GHV GENT BONE C|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|5.18||||0.10||| C1776|EAP|0278|BONE CEMENT ANTIBOTIC SIM|Workers Compensation|WORKERS COMPENSATION OTHER|790.75||||||| C1776|EAP|0278|ALL POLY PATELLA SZ 38X9.|Workers Compensation|WORKERS COMPENSATION OTHER|9.05||||||| C1776|EAP|0278|THR TOTAL HIP REPLACEMENT|NON CONTRACTED|COMMERCIAL OTHER 1|56.10||||||| C1776|EAP|0272||Medicare|MEDICARE ACUTE|5.18||||1,761.75||| C1776|EAP|0278|SMART SET GHV GENT BONE C|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|5.18||||||| C1776|EAP|0272||Medicare|MEDICARE ACUTE|2.21||||1,761.75||| C1776|EAP|0272||Medicare|MEDICARE ACUTE|202.75||||1,761.75||| C1776|EAP|0272||Medicare|MEDICARE ACUTE|417.75||||1,761.75||| C1776|EAP|0278|REVERSE SHOULDER-GLENOSPH|Medicare|MEDICARE ACUTE|2,938.50||||56.10||| C1776|EAP|0278|DISTAL RADIUS PLT NARROW/|Blue Cross PPO Specialty|BCBSTX PPO|14.06||||1,761.75||| C1776|EAP|0278|THR TOTAL HIP REPLACEMENT|Medicare|MEDICARE ACUTE|56.10||||56.10||| C1776|EAP|0278|STANDARD DISTAL RADIUS PL|Medicare|MEDICARE ACUTE|1,759.75||||56.10||| C1776|EAP|0278|NCB CANCELLOUS SCREW 5.0X|Blue Cross PPO Specialty|BCBSTX PPO|2.53||||4,627.50||| C1776|EAP|0278|STANDARD DISTAL RADIUS PL|Medicare|MEDICARE ACUTE|12.14||||1,759.75||| C1776|EAP|0278|SMART SET GHV GENT BONE C|Medicare|MEDICARE ACUTE|5.18||||56.10||| C1776|EAP|0278|REVERSE SHOULDER-GLENOSPH|Medicare|MEDICARE ACUTE|4.52||||2,938.50||| C1776|EAP|0278|RETENTIVE LINER + OMM OFF|Medicare|MEDICARE ACUTE|1,906.25||||56.10||| C1776|EAP|0278|PERI/DISTAL LAT FIB LKG P|Medicare|MEDICARE ACUTE|962.50||||56.10||| C1776|EAP|0278|PATELLA MEDIALIZED DOME 4|Medicare|MEDICARE ACUTE|786.25||||56.10||| C1776|EAP|0278|RETENTIVE LINER + OMM OFF|Humana Medicare Advantage|HUMANA MA|1,906.25||||2,915.50||| C1776|EAP|0278|PATELLA (ZIMMER)|Medicare|MEDICARE ACUTE|1,115.75||||56.10||| C1776|EAP|0278|NCB PROXIMAL TIBIA PLATE|Medicare|MEDICARE ACUTE|2,559.25||||56.10||| C1776|EAP|0278|MAGNUM 2 IMPLANT|Medicare|MEDICARE ACUTE|2,697.75||||4,627.50||| C1776|EAP|0278|LOCKING CAP NCB|Medicare|MEDICARE ACUTE|2,915.50||||326.50||| C1776|EAP|0278|CANNULA DISP/6.0MM X 75MM|Humana Medicare Advantage|HUMANA MA|790.75||||0.10||| C1776|EAP|0278|LOCKING CAP NCB|Medicare|MEDICARE ACUTE|326.50||||56.10||| C1776|EAP|0278|PATELLA MEDICALIZED DOME|Medicare|MEDICARE ACUTE|786.25||||56.10||| C1776|EAP|0278|JOINT DEVICE IMPLANTABLE|Medicare|MEDICARE ACUTE|790.75||||26.00||| C1776|EAP|0278|CANNULA DISP/6.0MM X 75MM|Medicare|MEDICARE ACUTE|9.05||||0.10||| C1776|EAP|0278|MAGNUM 2 IMPLANT|Humana Medicare Advantage|HUMANA MA|326.50||||4,627.50||| C1776|EAP|0278|ACU-LOC PLATE/NARROW RT|Medicare|MEDICARE ACUTE|417.75||||16.94||| C1776|EAP|0278|NCB CANCELLOUS SCREW 5.0X|Medicare|MEDICARE ACUTE|2.53||||56.10||| C1776|EAP|0278|THR TOTAL HIP REPLACEMENT|Medicare|MEDICARE ACUTE|26.00||||56.10||| C1776|EAP|0278|THREADED PIN 3.0MMX305MM|Medicare|MEDICARE ACUTE|2.21||||56.10||| C1776|EAP|0278|SMART SET GHV GENT BONE C|Tricare|TRICARE EAST REGION|5.18||||||| C1776|EAP|0278|JOINT DEVICE IMPLANTABLE|Tricare|TRICARE EAST REGION|42.50||||||| C1776|EAP|0278|THREADED PIN 3.0MMX305MM|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.21||||||| C1776|EAP|0278|3.2 THREADED PIN|UTMB|UTMB CORRECTIONAL MANAGED CARE|417.75||||||| C1776|EAP|0278|THR TOTAL HIP REPLACEMENT|Blue Cross PPO Specialty|BCBSTX PPO|56.10||||4,627.50||| C1776|EAP|0272||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.18||||||| C1776|EAP|0278|THR TOTAL HIP REPLACEMENT|Managed Medicaid|MEDICAID SUPERIOR|56.10||||||| C1776|EAP|0278|SMART SET GHV GENT BONE C|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|5.18||||5.00||| C1776|EAP|0278|PATELLA MEDICALIZED DOME|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|786.25||||5.00||| C1776|EAP|0278|JOINT DEVICE IMPLANTABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|15.00||||5.00||| C1776|EAP|0278|JOINT DEVICE IMPLANTABLE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|790.75||||5.00||| C1776|EAP|0278|JOINT DEVICE IMPLANTABLE|Managed Medicaid|MEDICAID AMERIGROUP|||||5.00||| C1776|EAP|0278|FLUTED STEM MOBIL TIBIAL|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2,697.75||||5.00||| C1776|EAP|0278|FEMORAL COMPONENT SZ F RT|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2,915.50||||5.00||| C1776|EAP|0278|CANNULA DISP/6.0MM X 75MM|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|9.05||||0.10||| C1776|EAP|0278|PERI/DISTAL LAT/FIB LKG P|Medicaid|MEDICAID|||||1,029.50||| C1778|EAP|0278|QUADRIPOLAR LEAD KIT FOR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||44.17||| C1778|EAP|0278|QUADRIPOLAR LEAD KIT FOR|United Healthcare|UNITED HEALTHCARE|||||44.17||| C1781|EAP|0278|PROLENE HERNIA MESH PHSE|Medicare|MEDICARE ACUTE|||||745.75||| C1781|EAP|0278|PROLENE HERNIA MESH PHSM&|Medicare|MEDICARE ACUTE|||||717.25||| C1781|EAP|0278|PROLENE HERNIA MESH PHSE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||745.75||| C1781|EAP|0278|PROLENE HERNIA MESH PHSE|Aenta Medicare Advantage|AETNA MEDICARE MA|||||745.75||| C1781|EAP|0278|PROLENE HERNIA MESH PHSE|Aetna|AETNA OTHER|||||745.75||| C1894|EAP|0278|LEAD INTRODUCER KIT|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||3.55||| C1894|EAP|0278|LEAD INTRODUCER KIT|United Healthcare|UNITED HEALTHCARE|||||3.55||| C9290|ERX|0636|BUPIVACAINE LIPOSOME 1.3%|Managed Medicare|BCBS MEDICARE PPO MA|||||1,786.50||| C9290|ERX|0636|BUPIVACAINE LIPOSOME 1.3%|Managed Medicaid|MEDICAID SUPERIOR|1,786.50||||1,786.50||| C9290|ERX|0636|BUPIVACAINE LIPOSOME 1.3%|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,786.50||||1,786.50||| C9290|ERX|0636|BUPIVACAINE LIPOSOME 1.3%|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1,786.50||| C9290|ERX|0636|BUPIVACAINE LIPOSOME 1.3%|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1,786.50||| C9290|ERX|0636|BUPIVACAINE LIPOSOME 1.3%|NON CONTRACTED|COMMERCIAL OTHER 1|1,786.50||||1,786.50||| C9290|ERX|0636|BUPIVACAINE LIPOSOME 1.3%|Medicare|MEDICARE ACUTE|1,786.50||||1,786.50||| C9290|ERX|0636|BUPIVACAINE LIPOSOME 1.3%|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|1,786.50||||1,786.50||| C9290|ERX|0636|BUPIVACAINE LIPOSOME 1.3%|Humana Medicare Advantage|HUMANA MA|1,786.50||||1,786.50||| C9290|ERX|0636|BUPIVACAINE LIPOSOME 1.3%|Tricare|TRICARE EAST REGION|1,786.50||||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%|Blue Cross PPO Specialty|BCBSTX OTHER|||||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||||1,786.50||| C9290|ERX|0636|BUPIVACAINE LIPOSOME 1.3%|Managed Medicaid|MEDICAID AMERIGROUP|||||1,786.50||| C9290|ERX|0636|BUPIVACAINE LIPOSOME 1.3%|Aenta Medicare Advantage|AETNA MEDICARE MA|1,786.50||||1,786.50||| C9290|ERX|0636|BUPIVACAINE LIPOSOME 1.3%|Blue Cross HMO Specialty|BCBSTX HMO|1,786.50||||1,786.50||| C9290|ERX|0636|BUPIVACAINE LIPOSOME 1.3%|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|1,786.50||||1,786.50||| C9290|ERX|0636|BUPIVACAINE LIPOSOME 1.3%|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|1,786.50||||1,786.50||| C9290|ERX|0636|BUPIVACAINE LIPOSOME 1.3%|Aetna|AETNA PPO|||||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%|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||||1,786.50||| C9290|ERX|0636|BUPIVACAINE LIPOSOME 1.3%|Veterans Affairs|VETERANS ADMINISTRATION|1,786.50||||1,786.50||| C9290|ERX|0636|BUPIVACAINE LIPOSOME 1.3%|United Healthcare|UNITED HEALTHCARE OTHER|||||1,786.50||| C9290|ERX|0636|BUPIVACAINE LIPOSOME 1.3%|United Healthcare|UNITED HEALTHCARE|||||1,786.50||| C9290|ERX|0636|BUPIVACAINE LIPOSOME 1.3%|Workers Compensation|WORKERS COMPENSATION OTHER|1,786.50||||||| G0103|EAP|0300|PSA SCREENING|United Healthcare|UNITED HEALTHCARE|||||140.50||| G0103|EAP|0300|PSA SCREENING|United Healthcare|TML GROUP BENEFITS|||||140.50||| G0103|EAP|0300|PSA SCREENING|United Healthcare|AARP|||||140.50||| G0103|EAP|0300|PSA SCREENING|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||140.50||| G0103|EAP|0300|PSA SCREENING|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||140.50||| G0103|EAP|0300|PSA SCREENING|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||140.50||| G0103|EAP|0300|PSA SCREENING|Workers Compensation|WORKERS COMPENSATION OTHER|||||140.50||| G0103|EAP|0300|PSA SCREENING|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||140.50||| G0103|EAP|0300|PSA SCREENING|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||140.50||| G0103|EAP|0300|PSA SCREENING|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||140.50||| G0103|EAP|0300|PSA SCREENING|Aenta Medicare Advantage|AETNA MEDICARE MA|||||140.50||| G0103|EAP|0300|PSA SCREENING|Blue Cross HMO Specialty|BCBSTX HMO|||||140.50||| G0103|EAP|0300|PSA SCREENING|Aetna|AETNA OTHER|||||140.50||| G0103|EAP|0300|PSA SCREENING|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||140.50||| G0103|EAP|0300|PSA SCREENING|United Medicare Advantage|UHC MEDICARE GOLD MA|||||140.50||| G0103|EAP|0300|PSA SCREENING|Humana Medicare Advantage|HUMANA MA|||||140.50||| G0103|EAP|0300|PSA SCREENING|Cigna|CIGNA|||||140.50||| G0103|EAP|0300|PSA SCREENING|Blue Cross PPO Specialty|BCBSTX PPO|||||140.50||| G0103|EAP|0300|PSA SCREENING|NON CONTRACTED|COMMERCIAL OTHER 1|||||140.50||| G0103|EAP|0300|PSA SCREENING|United Healthcare|UNITED HEALTHCARE OTHER|||||140.50||| G0103|EAP|0300|PSA SCREENING|Medicare|MEDICARE ACUTE|1.77||||140.50||| G0103|EAP|0300|PSA SCREENING|Tricare|TRICARE EAST REGION|||||140.50||| G0103|EAP|0300|PSA SCREENING|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||140.50||| G0103|EAP|0300|PSA SCREENING|Managed Medicare|HEALTHSPRING MA|||||140.50||| G0103|EAP|0300|PSA SCREENING|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||140.50||| G0103|EAP|0300|PSA SCREENING|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||140.50||| G0103|EAP|0300|PSA SCREENING|Managed Medicaid|MEDICAID AMERIGROUP|||||140.50||| G0103|EAP|0300|PSA SCREENING|Medicaid|MEDICAID|||||140.50||| G0103|EAP|0300|PSA SCREENING|Medicaid|MEDICAID HMO|||||140.50||| G0272|EAP|0450||Medicare|MEDICARE ACUTE|||||516.50||| G0297|EAP|0350|CT LUNG SCREENING|Humana Medicare Advantage|HUMANA MA|||||1.56||| G0297|EAP|0350|CT LUNG SCREENING|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||1.56||| G0297|EAP|0350|CT LUNG SCREENING|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.56||| G0297|EAP|0350|CT LUNG SCREENING|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1.56||| G0297|EAP|0350|CT LUNG SCREENING|Managed Medicare|HEALTHSPRING MA|||||1.56||| G0297|EAP|0350|CT LUNG SCREENING|NON CONTRACTED|COMMERCIAL OTHER 1|||||1.56||| G0297|EAP|0350|CT LUNG SCREENING|Tricare|TRICARE EAST REGION|||||1.56||| G0297|EAP|0350|CT LUNG SCREENING|Medicare|MEDICARE ACUTE|||||1.56||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|NON CONTRACTED|COMMERCIAL OTHER 2|||||156.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|Medicaid|MEDICAID|156.75||||156.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||156.75||| G0378|EAP|0762||Medicaid|MEDICAID|156.75||||247.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|Medicaid|MEDICAID HMO|||||156.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|Medicaid|SUPERIOR HEALTHPLAN CHIP|156.75||||||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|Rusk State Hospital|RUSK STATE HOSP|156.75||||||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||156.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|Tricare|TRICARE EAST REGION|||||156.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|UTMB|UTMB CORRECTIONAL MANAGED CARE|156.75||||156.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|Medicare|MEDICARE PART B ONLY IP|156.75||||||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|Medicare|MEDICARE ACUTE|156.75||||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 CIGNA HEALTHSPRING|156.75||||156.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|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 SUPERIOR|247.75||||247.75||| G0378|EAP|0762||Managed Medicaid|MEDICAID AMERIGROUP|156.75||||247.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||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||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|Veterans Affairs|VETERANS ADMINISTRATION|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 Healthcare|UNITED HEALTHCARE|||||156.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|United Healthcare|UMR UNITED MEDICAL RESOURCES|156.75||||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 -|NON CONTRACTED|COMMERCIAL OTHER 1|156.75||||156.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|Aenta Medicare Advantage|AETNA MEDICARE MA|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 -|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|156.75||||156.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||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 -|Blue Cross PPO Specialty|BCBSTX PPO|156.75||||156.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|Blue Cross PPO Specialty|BCBSTX OTHER|||||156.75||| G0378|EAP|0762||Blue Cross PPO Specialty|BCBSTX PPO|156.75||||247.75||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|Cigna|CIGNA|156.75||||||| G0378|EAP|0762|OBSERVATION ROOM PER HR -|Cigna|CIGNA|||||156.75||| G0379|EAP|0762|OBSERVATION DIRECT ADMISS|Blue Cross PPO Specialty|BCBSTX PPO|247.75||||247.75||| G0379|EAP|0762|OBSERVATION DIRECT ADMISS|Blue Cross PPO Specialty|BCBSTX OTHER|||||247.75||| G0379|EAP|0762|OBSERVATION DIRECT ADMISS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||247.75||| G0379|EAP|0762|OBSERVATION DIRECT ADMISS|Aenta Medicare Advantage|AETNA MEDICARE MA|247.75||||||| G0379|EAP|0762|OBSERVATION DIRECT ADMISS|Blue Cross HMO Specialty|BCBSTX HMO|||||247.75||| G0379|EAP|0762|OBSERVATION DIRECT ADMISS|Aetna|AETNA PPO|||||247.75||| G0379|EAP|0762|OBSERVATION DIRECT ADMISS|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||247.75||| G0379|EAP|0762|OBSERVATION DIRECT ADMISS|Veterans Affairs|VETERANS ADMINISTRATION|247.75||||||| G0379|EAP|0762|OBSERVATION DIRECT ADMISS|Managed Medicaid|MEDICAID SUPERIOR|247.75||||||| G0379|EAP|0762|OBSERVATION DIRECT ADMISS|Managed Medicaid|MEDICAID AMERIGROUP|||||247.75||| G0379|EAP|0762|OBSERVATION DIRECT ADMISS|Medicaid|MEDICAID|247.75||||||| G0463|EAP|0761|TREATMENT ROOM EST PT L-4|Medicare|MEDICARE ACUTE|||||6.38||| G0463|EAP|0761|EVAL/NP L-4 45 MIN|Medicare|MEDICARE ACUTE|||||409.50||| G0463|EAP|0761||Medicare|MEDICARE ACUTE|||||679.75||| G0463|EAP|0761||Medicare|MEDICARE ACUTE|||||3.83||| G0463|EAP|0761||Medicare|MEDICARE ACUTE|||||3.10||| G0463|EAP|0761|TREATMENT ROOM EST PT L-4|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||6.38||| G0463|EAP|0761|EVAL/NP L-4 45 MIN|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||409.50||| G0463|EAP|0761|TREATMENT ROOM EST PT L-4|United Medicare Advantage|UHC MEDICARE GOLD MA|||||6.38||| G0463|EAP|0761||Medicare|MEDICARE ACUTE|||||6.38||| G0463|EAP|0761|TREATMENT ROOM EST PT L-4|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||6.38||| G0463|EAP|0761|EVAL/NP L-4 45 MIN|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||409.50||| G0463|EAP|0761||United Medicare Advantage|UHC MEDICARE GOLD MA|||||679.75||| G0463|EAP|0761||United Medicare Advantage|UHC MEDICARE GOLD MA|||||3.83||| G0463|EAP|0761||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||679.75||| G0463|EAP|0761||United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||679.75||| G0463|EAP|0761||United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||6.38||| G0463|EAP|0761||United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||3.83||| G0463|EAP|0761||Aenta Medicare Advantage|AETNA MEDICARE MA|||||3.83||| G0463|EAP|0761|TREATMENT ROOM EST PT L-4|Humana Medicare Advantage|HUMANA MA|||||6.38||| G0463|EAP|0761|EVAL/NP L-4 45 MIN|Humana Medicare Advantage|HUMANA MA|||||409.50||| G0463|EAP|0761||Humana Medicare Advantage|HUMANA MA|||||679.75||| G0463|EAP|0761||Humana Medicare Advantage|HUMANA MA|||||6.38||| G0463|EAP|0761||Humana Medicare Advantage|HUMANA MA|||||3.83||| G0480|EAP|0300||Humana Medicare Advantage|HUMANA MA|2.72||||2.72||| G0480|EAP|0301||Humana Medicare Advantage|HUMANA MA|775.25||||775.25||| G0480|EAP|0301||Humana Medicare Advantage|HUMANA MA|4.14||||4.14||| G0480|EAP|0300||United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||2.72||| G0480|EAP|0300||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||2.72||| G0480|EAP|0301||United Medicare Advantage|UHC MEDICARE GOLD MA|4.14||||4.14||| G0480|EAP|0301||United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||775.25||| 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|||||775.25||| G0480|EAP|0301||United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||4.14||| G0480|EAP|0301||United Medicare Advantage|UHC MEDICARE GOLD MA|4.14||||775.25||| G0480|EAP|0301||Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||4.14||| G0480|EAP|0300||Medicare|MEDICARE ACUTE|||||2.72||| G0480|EAP|0301||Medicare|MEDICARE ACUTE|775.25||||775.25||| G0480|EAP|0301||Medicare|MEDICARE ACUTE|4.14||||4.14||| J0129|ERX|0636|ABATACEPT 250MG VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||136.80||| J0132|ERX|0636|ACETYLCYSTEINE 20%, 30ML|Medicare|MEDICARE ACUTE|1,315.20||||||| J0132|ERX|0636|ACETYLCYSTEINE 20%, 30ML|Managed Medicaid|MEDICAID AMERIGROUP|||||1,315.20||| J0153|ERX|0636|ADENOSINE 3MG/ML, 2ML VIA|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||123.75||| J0153|ERX|0636|ADENOSINE 3MG/ML, 2ML VIA|Blue Cross PPO Specialty|BCBSTX PPO|||||123.75||| J0153|ERX|0636|ADENOSINE 3MG/ML, 2ML VIA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|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||| J0558|ERX|0636|PEN G BENZ-PROCAINE 1.2MU|Managed Medicaid|MEDICAID SUPERIOR|||||44.95||| J0561|ERX|0636|PENICILLIN G BENZATHINE 1|Blue Cross PPO Specialty|BCBSTX PPO|||||42.79||| J0561|ERX|0636|PENICILLIN G BENZATHINE 1|Cigna|CIGNA|||||42.79||| J0561|ERX|0636|PENICILLIN G BENZATHINE 1|Managed Medicaid|MEDICAID SUPERIOR|||||42.79||| J0561|ERX|0636|PENICILLIN G BENZATHINE 1|Managed Medicaid|MEDICAID AMERIGROUP|||||42.79||| J0585|ERX|0636|BOTULINUM TOXIN 100 UNIT|Medicare|MEDICARE ACUTE|27.40||||27.40||| J0585|ERX|0636|BOTULINUM TOXIN 100 UNIT|Managed Medicaid|MEDICAID AMERIGROUP|||||27.40||| J0585|ERX|0636|BOTULINUM TOXIN 100 UNIT|Veterans Affairs|VETERANS ADMINISTRATION|||||27.40||| J0585|ERX|0636|BOTULINUM TOXIN 100 UNIT|Humana Medicare Advantage|HUMANA MA|||||27.40||| J0585|ERX|0636|BOTULINUM TOXIN 100 UNIT|Blue Cross PPO Specialty|BCBSTX PPO|||||27.40||| J0690|ERX|0250||Humana Medicare Advantage|HUMANA MA|95.75||||95.75||| J0690|ERX|0250||United Medicare Advantage|UHC MEDICARE GOLD MA|||||95.75||| J0690|ERX|0250||United Medicare Advantage|AARP UHC WEST COMPLETE MA|95.75||||95.75||| J0690|ERX|0250||Medicare|MEDICARE ACUTE|95.75||||95.75||| J0690|ERX|0250||Tricare|TRICARE EAST REGION|||||95.75||| J0712|ERX|0636|CEFTAROLINE 600 MG NS MB+|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.54||| J0712|ERX|0636|CEFTAROLINE 600 MG NS MB+|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.54||||0.54||| J0712|ERX|0636|CEFTAROLINE 600 MG NS MB+|Rusk State Hospital|RUSK STATE HOSP|0.54||||||| J0712|ERX|0636|CEFTAROLINE 600 MG NS MB+|Tricare|TRICARE EAST REGION|||||0.54||| J0712|ERX|0636|CEFTAROLINE 600 MG NS MB+|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.54||||0.54||| J0712|ERX|0636|CEFTAROLINE 600 MG VIAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.54||||0.54||| J0712|ERX|0636|CEFTAROLINE 600 MG NS MB+|Medicare|MEDICARE ACUTE|0.54||||0.54||| J0712|ERX|0636|CEFTAROLINE 600 MG NS MB+|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.54||||||| J0712|ERX|0636|CEFTAROLINE 600 MG NS MB+|Humana Medicare Advantage|HUMANA MA|0.54||||||| J0712|ERX|0636|CEFTAROLINE 600 MG VIAL|Humana Medicare Advantage|HUMANA MA|0.54||||||| J0712|ERX|0636|CEFTAROLINE 600 MG NS MB+|Blue Cross PPO Specialty|BCBSTX PPO|0.54||||0.54||| J0834|ERX|0636|COSYNTROPIN 0.25MG VIAL|Humana Medicare Advantage|HUMANA MA|||||549.97||| J0834|ERX|0636|COSYNTROPIN 0.25MG VIAL|Medicare|MEDICARE ACUTE|549.97||||||| J0840|ERX|0250|ANTIVENIN,CROTALIDAE 1 VI|Managed Medicaid|MEDICAID SUPERIOR|||||12,912.75||| J0885|ERX|0636|EPOETIN 20000 UNIT/1ML|Medicare|MEDICARE ACUTE|133.90||||||| J0897|ERX|0636|DENOSUMAB 60 MG/ML SYRING|United Medicare Advantage|UHC MEDICARE GOLD MA|||||73.35||| J0897|ERX|0636|DENOSUMAB 60 MG/ML SYRING|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||73.35||| J0897|ERX|0636|DENOSUMAB 60 MG/ML SYRING|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||73.35||| J0897|ERX|0636|DENOSUMAB 60 MG/ML SYRING|Aenta Medicare Advantage|AETNA MEDICARE MA|||||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|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||73.35||| J0897|ERX|0636|DENOSUMAB 60 MG/ML SYRING|Humana Medicare Advantage|HUMANA MA|||||73.35||| J0897|ERX|0636|DENOSUMAB 60 MG/ML SYRING|Medicare|MEDICARE ACUTE|||||73.35||| J1160|ERX|0636|DIGOXIN 250MCG 1ML|Managed Medicare|HEALTHSPRING MA|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|UTMB|UTMB CORRECTIONAL MANAGED CARE|38.28||||||| J1160|ERX|0636|DIGOXIN 250MCG 1ML|Medicare|MEDICARE ACUTE|38.28||||||| J1160|ERX|0636|DIGOXIN 250MCG 1ML|Humana Medicare Advantage|HUMANA MA|38.28||||||| J1160|ERX|0636|DIGOXIN 250MCG 1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||38.28||| J1160|ERX|0636|DIGOXIN 250MCG 1ML|Aenta Medicare Advantage|AETNA MEDICARE MA|38.28||||||| J1160|ERX|0636|DIGOXIN 250MCG 1ML|United Medicare Advantage|AARP UHC WEST COMPLETE 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|Veterans Affairs|VETERANS ADMINISTRATION|38.28||||||| J1335|ERX|0250|ERTAPENEM 1 GM/100ML NS M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||610.25||| J1442|ERX|0250|FILGRASTIM 300MCG/1ML|Humana Medicare Advantage|HUMANA MA|7.06||||||| J1442|ERX|0250|FILGRASTIM 300MCG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|7.06||||||| J1447|ERX|0636|TBO-FILGRASTIM 300MCG/0.5|Humana Medicare Advantage|HUMANA MA|4.62||||||| J1459|ERX|0636|PRIVIGEN 20G/200ML|Medicare|MEDICARE ACUTE|||||217.55||| J1459|ERX|0636|IMMUNE GLOBULIN IV (PRIVI|Medicare|MEDICARE ACUTE|||||203.74||| J1561|ERX|0636|GAMUNEX-C 20G/200ML|Medicare|MEDICARE ACUTE|||||249.96||| J1561|ERX|0636|GAMUNEX-C 10G/100ML|Medicare|MEDICARE ACUTE|||||249.96||| J1568|ERX|0636|OCTAGAM (10%) 20 GM/200 M|Humana Medicare Advantage|HUMANA MA|||||1.90||| J1568|ERX|0636|OCTAGAM (5%) 10 GMM/200 M|Blue Cross PPO Specialty|BCBSTX PPO|||||1,662.25||| J1568|ERX|0636|OCTAGAM (5%) 5 GM/100 ML|Medicare|MEDICARE ACUTE|340.20||||||| J1580|ERX|0250|GENTAMICIN 80MG/100ML NS|Medicaid|MEDICAID|103.25||||||| J1580|ERX|0250|GENTAMICIN 80MG/100ML NS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|103.25||||103.25||| J1580|ERX|0250|GENTAMICIN 80MG/100ML NS|Managed Medicaid|MEDICAID AMERIGROUP|103.25||||103.25||| J1580|ERX|0250|GENTAMICIN 80MG/100ML NS|Managed Medicaid|MEDICAID SUPERIOR|103.25||||103.25||| J1580|ERX|0250|GENTAMICIN 80MG/100ML NS|NON CONTRACTED|COMMERCIAL OTHER 1|103.25||||103.25||| J1580|ERX|0250|GENTAMICIN 80MG/100ML NS|Medicare|MEDICARE ACUTE|103.25||||103.25||| J1580|ERX|0250|GENTAMICIN 80MG/100ML NS|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||103.25||| J1580|ERX|0250|GENTAMICIN 80MG/100ML NS|Tricare|TRICARE EAST REGION|103.25||||||| J1580|ERX|0250|GENTAMICIN 80MG/100ML NS|UTMB|UTMB CORRECTIONAL MANAGED CARE|103.25||||||| J1580|ERX|0250|GENTAMICIN 80MG/100ML NS|United Healthcare|UNITED HEALTHCARE|||||103.25||| J1580|ERX|0250|GENTAMICIN 80MG/100ML NS|United Healthcare|UNITED HEALTHCARE OTHER|||||103.25||| J1580|ERX|0250|GENTAMICIN 80MG/100ML NS|Workers Compensation|WORKERS COMPENSATION OTHER|103.25||||103.25||| J1580|ERX|0250|GENTAMICIN 80MG/100ML NS|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|103.25||||103.25||| J1580|ERX|0250|GENTAMICIN 80MG/100ML NS|Medicare|MEDICARE PART B ONLY IP|||||103.25||| J1580|ERX|0250|GENTAMICIN 80MG/100ML NS|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||103.25||| J1580|ERX|0250|GENTAMICIN 80MG/100ML NS|United Medicare Advantage|AARP UHC WEST COMPLETE MA|103.25||||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|United Medicare Advantage|UHC MEDICARE GOLD MA|103.25||||103.25||| J1580|ERX|0250|GENTAMICIN 80MG/100ML NS|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|103.25||||103.25||| J1580|ERX|0250|GENTAMICIN 80MG/100ML NS|Managed Medicare|HEALTHSPRING MA|||||103.25||| J1580|ERX|0250|GENTAMICIN 80MG/100ML NS|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||103.25||| J1580|ERX|0250|GENTAMICIN 80MG/100ML NS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|103.25||||103.25||| J1580|ERX|0250|GENTAMICIN 80MG/100ML NS|Aenta Medicare Advantage|AETNA MEDICARE MA|103.25||||103.25||| J1580|ERX|0250|GENTAMICIN 80MG/100ML NS|Blue Cross HMO Specialty|BCBSTX HMO|103.25||||103.25||| J1580|ERX|0250|GENTAMICIN 80MG/100ML NS|Aetna|AETNA PPO|||||103.25||| J1580|ERX|0250|GENTAMICIN 80MG/100ML NS|Blue Cross PPO Specialty|BCBSTX OTHER|||||103.25||| J1580|ERX|0250|GENTAMICIN 80MG/100ML NS|Blue Cross PPO Specialty|BCBSTX PPO|103.25||||103.25||| J1580|ERX|0250|GENTAMICIN 80MG/100ML NS|Humana Medicare Advantage|HUMANA MA|103.25||||103.25||| J1580|ERX|0250|GENTAMICIN 80MG/100ML NS|Cigna|CIGNA|103.25||||||| J1580|ERX|0250|GENTAMICIN 80MG/100ML NS|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|103.25||||||| J1610|ERX|0250|GLUCAGON 1MG VIAL|Humana Medicare Advantage|HUMANA MA|||||891.50||| J1610|ERX|0250|GLUCAGON 1MG VIAL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||891.50||| J1610|ERX|0250|GLUCAGON 1MG VIAL|Medicare|MEDICARE ACUTE|891.50||||891.50||| J1745|ERX|0636|INFLIXIMAB 100MG VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||508.65||| J1745|ERX|0636|INFLIXIMAB 100MG VIAL|Blue Cross HMO Specialty|BCBSTX HMO|||||508.65||| J1745|ERX|0636|INFLIXIMAB 100MG VIAL|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||508.65||| J1745|ERX|0636|INFLIXIMAB 100MG VIAL|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||508.65||| J1745|ERX|0636|INFLIXIMAB 100MG VIAL|Access Direct Platinum|HEALTHFIRST TPA UMR|||||508.65||| J1745|ERX|0636|INFLIXIMAB 100MG VIAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||508.65||| J1745|ERX|0636|INFLIXIMAB 100MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|||||508.65||| J1750|ERX|0636|IRON DEXTRAN 50MG/ML, 2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||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|United Healthcare|UNITED HEALTHCARE OTHER|6.11||||6.11||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|6.11||||||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|Brinson Benefits|THE HEALTH PLAN SMITH CO|6.11||||||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|Blue Cross PPO Specialty|BCBSTX PPO|6.11||||||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|Cigna|CIGNA|6.11||||||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|Medicaid|MEDICAID|6.11||||||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|UTMB|UTMB CORRECTIONAL MANAGED CARE|6.11||||||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|Medicare|MEDICARE ACUTE|6.11||||||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|Managed Medicaid|MEDICAID SUPERIOR|6.11||||6.11||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||6.11||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|Managed Medicaid|MEDICAID AMERIGROUP|6.11||||6.11||| J1756|ERX|0636|IRON SUCROSE COMPL. 100/M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|6.11||||||| J1953|ERX|0636|LEVETIRACETAM 1000MG IN 1|UTMB|UTMB CORRECTIONAL MANAGED CARE|521.75||||521.75||| J1953|ERX|0636|LEVETIRACETAM 1000MG IN 1|Medicare|MEDICARE ACUTE|521.75||||521.75||| J1953|ERX|0636|LEVETIRACETAM 1000MG IN 1|Humana Medicare Advantage|HUMANA MA|521.75||||||| J1953|ERX|0636|LEVETIRACETAM 1000MG IN 1|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||521.75||| J1953|ERX|0636|LEVETIRACETAM 1000MG IN 1|Aenta Medicare Advantage|AETNA MEDICARE MA|521.75||||||| J2020|ERX|0636|LINEZOLID 600MG/300ML D5W|United Medicare Advantage|UHC MEDICARE GOLD MA|4.80||||||| J2020|ERX|0636|LINEZOLID 600MG/300ML D5W|United Medicare Advantage|AARP UHC WEST COMPLETE MA|4.80||||||| J2020|ERX|0636|LINEZOLID 600MG/300ML D5W|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|4.80||||||| J2020|ERX|0636|LINEZOLID 600MG/300ML D5W|Aenta Medicare Advantage|AETNA MEDICARE MA|4.80||||||| J2020|ERX|0636|LINEZOLID 600MG/300ML D5W|Humana Medicare Advantage|HUMANA 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|Managed Medicare|HEALTHSPRING MA|4.80||||||| J2020|ERX|0636|LINEZOLID 600MG/300ML D5W|Managed Medicaid|MEDICAID UNITED HEALTHCARE|4.80||||||| J2020|ERX|0636|LINEZOLID 600MG/300ML D5W|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|4.80||||||| J2020|ERX|0636|LINEZOLID 600MG/300ML D5W|Medicaid|MEDICAID|4.80||||||| J2020|ERX|0636|LINEZOLID 600MG/300ML D5W|Rusk State Hospital|RUSK STATE HOSP|4.80||||||| J2020|ERX|0636|LINEZOLID 600MG/300ML D5W|UTMB|UTMB CORRECTIONAL MANAGED CARE|4.80||||||| J2020|ERX|0636|LINEZOLID 600MG/300ML D5W|Medicare|MEDICARE ACUTE|4.80||||||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Medicaid|MEDICAID|16.75||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Medicaid|SUPERIOR HEALTHPLAN CHIP|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Medicaid|SUPERIOR HEALTHPLAN CHIP|16.75||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|NON CONTRACTED|COMMERCIAL OTHER 1|0.16||||16.75||| J2270|ERX|0636|MORPHINE 10MG/1ML|NON CONTRACTED|COMMERCIAL OTHER 1|16.75||||16.75||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Tricare|TRICARE EAST REGION|0.16||||0.16||| J2270|ERX|0636|MORPHINE 10MG/1ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.16||||16.75||| J2270|ERX|0636|MORPHINE 10MG/1ML|Medicare|MEDICARE ACUTE|16.75||||16.75||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Medicare|MEDICARE ACUTE|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Managed Medicare|HEALTHSPRING MA|0.16||||16.75||| J2270|ERX|0636|MORPHINE 10MG/1ML|Managed Medicare|HEALTHSPRING MA|16.75||||16.75||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Managed Medicare|HOSPICE OF EAST TEXAS|0.16||||||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Managed Medicaid|MEDICAID AMERIGROUP|0.16||||0.16||| J2270|ERX|0636|MORPHINE 10MG/1ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|16.75||||16.75||| J2270|ERX|0636|MORPHINE 10MG/1ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.16||||16.75||| J2270|ERX|0636|MORPHINE 10MG/1ML|Managed Medicaid|MEDICAID AMERIGROUP|16.75||||16.75||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||0.16||| J2270|ERX|0636|MORPHINE 10MG/1ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|0.16||||16.75||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Humana Medicare Advantage|HUMANA MA|0.16||||0.16||| J2270|ERX|0636|MORPHINE 10MG/1ML|Humana Medicare Advantage|HUMANA MA|16.75||||16.75||| J2270|ERX|0636|MORPHINE 10MG/1ML|Managed Medicaid|MEDICAID SUPERIOR|16.75||||16.75||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Blue Cross PPO Specialty|BCBSTX PPO|0.16||||0.16||| J2270|ERX|0636|MORPHINE 10MG/1ML|Blue Cross PPO Specialty|BCBSTX PPO|16.75||||16.75||| J2270|ERX|0636|MORPHINE 10MG/1ML|Cigna|CIGNA|16.75||||||| 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|Managed Medicaid|MEDICAID SUPERIOR|0.16||||0.16||| J2270|ERX|0636|MORPHINE 10MG/1ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|16.75||||16.75||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Aenta Medicare Advantage|AETNA MEDICARE MA|16.75||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Aenta Medicare Advantage|AETNA MEDICARE MA|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Blue Cross HMO Specialty|BCBSTX HMO|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.16||||0.16||| J2270|ERX|0636|MORPHINE 10MG/1ML|Blue Cross HMO Specialty|BCBSTX HMO|0.16||||16.75||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.16||||0.16||| J2270|ERX|0636|MORPHINE 10MG/1ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|16.75||||16.75||| J2270|ERX|0636|MORPHINE 10MG/1ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.16||||16.75||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Medicaid|MEDICAID|0.16||||0.16||| J2270|ERX|0636|MORPHINE 10MG/1ML|Aetna|AETNA PPO|||||16.75||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|United Medicare Advantage|UHC MEDICARE GOLD MA|0.16||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.16||||0.16||| J2270|ERX|0636|MORPHINE 10MG/1ML|United Medicare Advantage|UHC MEDICARE GOLD MA|16.75||||16.75||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||0.16||| J2270|ERX|0636|MORPHINE 10MG/1ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|16.75||||16.75||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|16.75||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|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|Veterans Affairs|VETERANS ADMINISTRATION|0.16||||16.75||| J2270|ERX|0636|MORPHINE 10MG/1ML|Veterans Affairs|VETERANS ADMINISTRATION|16.75||||16.75||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|United Healthcare|UNITED HEALTHCARE OTHER|16.75||||0.16||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|United Healthcare|UNITED HEALTHCARE|0.16||||||| J2270|ERX|0636|MORPHINE 2MG/ML SYRINGE|Workers Compensation|WORKERS COMPENSATION OTHER|0.16||||0.16||| J2270|ERX|0636|MORPHINE 10MG/1ML|Workers Compensation|WORKERS COMPENSATION OTHER|0.16||||16.75||| J2325|ERX|0636|NESIRITIDE 1.5MG VIAL|Humana Medicare Advantage|HUMANA MA|342.25||||||| J2357|ERX|0636|OMALIZUMAB 150MG VIAL|Medicare|MEDICARE ACUTE|||||143.69||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|Veterans Affairs|VETERANS ADMINISTRATION|16.80||||16.80||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|Workers Compensation|WORKERS COMPENSATION OTHER|16.80||||16.80||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|Workers Compensation|UT EMPLOYEE INJURY|16.80||||||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|United Healthcare|TML GROUP BENEFITS|||||16.80||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|United Healthcare|UMR UNITED MEDICAL RESOURCES|16.80||||16.80||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|United Healthcare|UNITED HEALTHCARE OTHER|16.80||||16.80||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|16.80||||16.80||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|16.80||||16.80||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|United Medicare Advantage|UHC MEDICARE GOLD MA|16.80||||16.80||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|16.80||||16.80||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|16.80||||16.80||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|Access Direct Platinum|HEALTHFIRST TPA UMR|||||16.80||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|16.80||||16.80||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|Aenta Medicare Advantage|AETNA MEDICARE MA|16.80||||16.80||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|Blue Cross HMO Specialty|BCBSTX HMO|16.80||||16.80||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|Aetna|AETNA OTHER|16.80||||16.80||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|Blue Cross PPO Specialty|BCBSTX OTHER|||||16.80||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|Blue Cross PPO Specialty|BCBSTX PPO|16.80||||16.80||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|Humana Medicare Advantage|HUMANA MA|16.80||||16.80||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|Aetna|AETNA PPO|16.80||||16.80||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|16.80||||16.80||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|Cigna|CIGNA|16.80||||||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|Cigna|CIGNA|16.80||||16.80||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|Cigna|CIGNA|||||16.80||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|16.80||||16.80||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|Managed Medicaid|MEDICAID AMERIGROUP|16.80||||16.80||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|16.80||||16.80||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|16.80||||16.80||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|16.80||||16.80||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|Managed Medicare|HEALTHSPRING MA|16.80||||16.80||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|Managed Medicare|BCBS MEDICARE PPO MA|||||16.80||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|16.80||||16.80||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|Managed Medicare|HOSPICE OF EAST TEXAS|16.80||||||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|United Healthcare|UNITED HEALTHCARE|16.80||||16.80||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||16.80||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|Medicaid|MEDICAID PCCM|||||16.80||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|Medicaid|MEDICAID HMO|||||16.80||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||16.80||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|Medicaid|MEDICAID|16.80||||16.80||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|Medicaid|COUNTY INDIGENT HEALTH OTHER|16.80||||16.80||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||16.80||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|Managed Medicaid|MEDICAID SUPERIOR|16.80||||16.80||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|NON CONTRACTED|COMMERCIAL OTHER 1|16.80||||16.80||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|Medicare|MEDICARE PART B ONLY IP|16.80||||||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|Medicare|MEDICARE ACUTE|16.80||||16.80||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|Rusk State Hospital|RUSK STATE HOSP|16.80||||16.80||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|16.80||||16.80||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|Tricare|TRICARE EAST REGION|16.80||||16.80||| J2405|ERX|0250|ONDANSETRON 4MG/2ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|16.80||||16.80||| J2597|ERX|0636|DESMOPRESSIN 4MCG/1ML|Medicare|MEDICARE ACUTE|98.38||||||| J2704|ERX|0636|PROPOFOL 100 MG/ 10 ML|Blue Cross PPO Specialty|BCBSTX PPO|||||1.50||| J2785|ERX|0636|REGADENOSON 0.4MG 5ML|Managed Medicare|HEALTHSPRING MA|||||1,442.50||| 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 SUPERIOR|||||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|NON CONTRACTED|COMMERCIAL OTHER 2|||||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|Tricare|TRICARE EAST REGION|||||1,442.50||| J2785|ERX|0636|REGADENOSON 0.4MG 5ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|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|UHC MEDICARE GOLD MA|||||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 Medicare|MEDICARE ADVANTAGE OTHER MA|||||1,442.50||| J2785|ERX|0636|REGADENOSON 0.4MG 5ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|1,442.50||||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|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||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||||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|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||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|Humana Medicare Advantage|HUMANA MA|1,442.50||||1,442.50||| J2785|ERX|0636|REGADENOSON 0.4MG 5ML|Blue Cross PPO Specialty|BCBSTX PPO|||||1,442.50||| J2785|ERX|0636|REGADENOSON 0.4MG 5ML|Blue Cross PPO Specialty|BCBSTX OTHER|||||1,442.50||| J2790|ERX|0636|HYPERRHO IMMUNE GLOBULIN|Blue Cross PPO Specialty|BCBSTX PPO|||||373.25||| J2790|ERX|0636|HYPERRHO IMMUNE GLOBULIN|Blue Cross HMO Specialty|BCBSTX HMO|373.25||||373.25||| J2790|ERX|0636|HYPERRHO IMMUNE GLOBULIN|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||373.25||| J2790|ERX|0636|HYPERRHO IMMUNE GLOBULIN|United Healthcare|UNITED HEALTHCARE OTHER|||||373.25||| J2790|ERX|0636|HYPERRHO IMMUNE GLOBULIN|United Healthcare|UNITED HEALTHCARE|373.25||||373.25||| J2790|ERX|0636|HYPERRHO IMMUNE GLOBULIN|Workers Compensation|WORKERS COMPENSATION OTHER|||||373.25||| J2790|ERX|0636|HYPERRHO IMMUNE GLOBULIN|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||373.25||| J2790|ERX|0636|HYPERRHO IMMUNE GLOBULIN|Medicaid|MEDICAID|373.25||||||| J2790|ERX|0636|HYPERRHO IMMUNE GLOBULIN|NON CONTRACTED|COMMERCIAL OTHER 2|||||373.25||| J2790|ERX|0636|HYPERRHO IMMUNE GLOBULIN|Managed Medicaid|MEDICAID SUPERIOR|373.25||||373.25||| J2790|ERX|0636|HYPERRHO IMMUNE GLOBULIN|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||373.25||| J2790|ERX|0636|HYPERRHO IMMUNE GLOBULIN|Managed Medicaid|MEDICAID AMERIGROUP|373.25||||373.25||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Managed Medicaid|MEDICAID SUPERIOR|60.25||||60.25||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Managed Medicaid|MEDICAID AMERIGROUP|60.25||||60.25||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|60.25||||60.25||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||60.25||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Managed Medicare|HEALTHSPRING MA|||||60.25||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Medicaid|MEDICAID TEXAS CHILDRENS|||||60.25||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|NON CONTRACTED|COMMERCIAL OTHER 1|60.25||||60.25||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Medicare|MEDICARE ACUTE|60.25||||60.25||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Rusk State Hospital|RUSK STATE HOSP|60.25||||60.25||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Medicaid|MEDICAID|60.25||||60.25||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Tricare|TRICARE EAST REGION|||||60.25||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||60.25||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Managed Medicaid|MEDICAID UNITED HEALTHCARE|60.25||||60.25||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Veterans Affairs|VETERANS ADMINISTRATION|60.25||||60.25||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|United Healthcare|UNITED HEALTHCARE|||||60.25||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|United Medicare Advantage|UHC MEDICARE GOLD MA|60.25||||60.25||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|60.25||||60.25||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|United Medicare Advantage|AARP UHC WEST COMPLETE MA|60.25||||60.25||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||60.25||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||60.25||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Aenta Medicare Advantage|AETNA MEDICARE MA|60.25||||60.25||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Blue Cross HMO Specialty|BCBSTX HMO|60.25||||60.25||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Blue Cross PPO Specialty|BCBSTX OTHER|||||60.25||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Blue Cross PPO Specialty|BCBSTX PPO|60.25||||60.25||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Humana Medicare Advantage|HUMANA MA|60.25||||60.25||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Cigna|CIGNA|||||60.25||| J2930|ERX|0250|METHYLPREDNISOLONE 125MG/|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||60.25||| J2997|ERX|0636|ALTEPLASE 100MG VIAL|Humana Medicare Advantage|HUMANA MA|329.08||||281.61||| J2997|ERX|0636|ALTEPLASE 2MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|||||329.08||| J2997|ERX|0636|ALTEPLASE 100MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|||||281.61||| J2997|ERX|0636|ALTEPLASE 100MG VIAL|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||281.61||| J2997|ERX|0636|ALTEPLASE 100MG VIAL|Aenta Medicare Advantage|AETNA MEDICARE MA|||||281.61||| J2997|ERX|0636|ALTEPLASE 100MG VIAL|Blue Cross HMO Specialty|BCBSTX HMO|281.61||||281.61||| J2997|ERX|0636|ALTEPLASE 2MG VIAL|UTMB|UTMB CORRECTIONAL MANAGED CARE|329.08||||||| J2997|ERX|0636|ALTEPLASE 100MG VIAL|Medicare|MEDICARE ACUTE|329.08||||281.61||| J2997|ERX|0636|ALTEPLASE 2MG VIAL|Managed Medicare|HEALTHSPRING MA|329.08||||||| J3101|ERX|0636|TENECTEPLASE 50MG 1 KIT|United Medicare Advantage|UHC MEDICARE GOLD MA|||||413.02||| J3357|ERX|0636|USTEKINUMAB 90 MG/ML SQ S|Humana Medicare Advantage|HUMANA MA|||||769.42||| J3358|ERX|0636|USTEKINUMAB 130 MG/26 ML|Humana Medicare Advantage|HUMANA MA|||||48.06||| J3370|ERX|0250|VANCOMYCIN 500MG/100ML NS|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.14||||||| J3370|ERX|0250|VANCOMYCIN 500MG/100ML NS|Medicare|MEDICARE ACUTE|0.14||||||| J3370|ERX|0250|VANCOMYCIN 500MG/100ML NS|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.14||||||| J3370|ERX|0250|VANCOMYCIN 500MG/100ML NS|Humana Medicare Advantage|HUMANA MA|0.14||||||| J3380|ERX|0636|VEDOLIZUMAB 300MG VIAL|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||70.17||| J3380|ERX|0636|VEDOLIZUMAB 300MG VIAL|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||70.17||| J3380|ERX|0636|VEDOLIZUMAB 300MG VIAL|Blue Cross PPO Specialty|BCBSTX PPO|||||70.17||| J3380|ERX|0636|VEDOLIZUMAB 300MG VIAL|Tricare|TRICARE EAST REGION|||||70.17||| J3489|ERX|0636|ZOLEDRONIC ACID 5 MG/100M|Medicare|MEDICARE ACUTE|||||3,777.20||| J3489|ERX|0636|ZOLEDRONIC ACID 5 MG/100M|Humana Medicare Advantage|HUMANA MA|||||3,777.20||| J3490|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|United Healthcare|UNITED HEALTHCARE|2.10||||||| J3490|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|2.10||||2.10||| J3490|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|United Medicare Advantage|AARP UHC WEST COMPLETE MA|2.10||||||| J3490|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|United Medicare Advantage|UHC MEDICARE GOLD MA|2.10||||||| J3490|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|2.10||||||| J3490|ERX|0258|NA CHLOR 0.9% KCL 40MEQ/1|Aenta Medicare Advantage|AETNA MEDICARE MA|2.10||||||| J3490|ERX|0258|NA CHLOR 0.9% KCL 40MEQ/1|Blue Cross HMO Specialty|BCBSTX HMO|2.10||||||| J3490|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|2.10||||||| J3490|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Blue Cross HMO Specialty|BCBSTX HMO|2.10||||||| J3490|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Aetna|AETNA OTHER|2.10||||||| J3490|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Blue Cross PPO Specialty|BCBSTX PPO|||||2.10||| J3490|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Humana Medicare Advantage|HUMANA MA|2.10||||||| J3490|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Veterans Affairs|VETERANS ADMINISTRATION|2.10||||||| J3490|ERX|0258|NA CHLOR 0.9% KCL 40MEQ/1|Humana Medicare Advantage|HUMANA MA|2.10||||||| J3490|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|2.10||||||| J3490|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Managed Medicaid|MEDICAID SUPERIOR|2.10||||2.10||| J3490|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|2.10||||||| J3490|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Managed Medicaid|MEDICAID UNITED HEALTHCARE|2.10||||||| J3490|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||2.10||| J3490|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Medicaid|MEDICAID|2.10||||||| J3490|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|NON CONTRACTED|COMMERCIAL OTHER 1|2.10||||||| J3490|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Medicare|MEDICARE ACUTE|2.10||||2.10||| J3490|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|Rusk State Hospital|RUSK STATE HOSP|2.10||||||| J3490|ERX|0258|SOD CHL 0.9% KCL 20MEQ/10|UTMB|UTMB CORRECTIONAL MANAGED CARE|2.10||||||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|NON CONTRACTED|COMMERCIAL OTHER 1|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|Medicare|MEDICARE ACUTE|0.85||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Tricare|TRICARE EAST REGION|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|Managed Medicare|HOSPICE OF EAST TEXAS|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 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 CIGNA HEALTHSPRING|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|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|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.85||||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||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Medicaid|MEDICAID PCCM|||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Medicaid|MEDICAID TEXAS CHILDRENS|||||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|Cigna|CIGNA|0.85||||||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Cigna|CIGNA|0.85||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Cigna|CIGNA|||||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|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|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|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.85||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Managed Medicare|BCBS MEDICARE PPO MA|||||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|Aenta Medicare Advantage|AETNA MEDICARE MA|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|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.85||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Rusk State Hospital|RUSK STATE HOSP|0.85||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Aetna|AETNA OTHER|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|United Healthcare|UNITED HEALTHCARE OTHER|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|0.85||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|United Healthcare|UMR UNITED MEDICAL RESOURCES|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|Workers Compensation|WORKERS COMPENSATION OTHER|0.85||||0.85||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Workers Compensation|UT EMPLOYEE INJURY|0.85||||||| J7030|ERX|0258|SODIUM CHLORIDE 0.9% 1000|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|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|United Medicare Advantage|UHC MEDICARE SOLUTIONS 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 DUAL COMPLETE HMO SNP MA|0.85||||0.85||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.25||||0.25||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.25||||0.25||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|United Healthcare|UNITED HEALTHCARE|||||0.25||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|United Healthcare|UNITED HEALTHCARE OTHER|0.25||||0.25||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Workers Compensation|UT EMPLOYEE INJURY|0.25||||||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|United Medicare Advantage|UHC MEDICARE GOLD MA|0.25||||0.25||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.25||||0.25||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.25||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Aenta Medicare Advantage|AETNA MEDICARE MA|0.25||||0.25||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Blue Cross HMO Specialty|BCBSTX HMO|0.25||||0.25||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Aetna|AETNA OTHER|0.25||||||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Aetna|AETNA PPO|0.25||||||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Blue Cross PPO Specialty|BCBSTX PPO|0.25||||0.25||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.25||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Access Direct Platinum|HEALTHFIRST TPA UMR|||||0.25||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Humana Medicare Advantage|HUMANA MA|0.25||||0.25||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Cigna|CIGNA|0.25||||||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.25||||0.25||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.25||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Veterans Affairs|VETERANS ADMINISTRATION|0.25||||||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Managed Medicare|HEALTHSPRING MA|||||0.25||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Managed Medicaid|MEDICAID SUPERIOR|0.25||||0.25||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Managed Medicaid|MEDICAID AMERIGROUP|0.25||||0.25||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.25||||0.25||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.25||||0.25||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Medicaid|MEDICAID|0.25||||0.25||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Medicaid|SUPERIOR HEALTHPLAN CHIP|0.25||||||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Medicaid|MEDICAID HMO|||||0.25||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|NON CONTRACTED|COMMERCIAL OTHER 1|0.25||||0.25||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Medicare|MEDICARE ACUTE|0.25||||0.25||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Medicare|MEDICARE PART B ONLY IP|0.25||||||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|Rusk State Hospital|RUSK STATE HOSP|0.25||||||| J7040|ERX|0258|SODIUM CHLORIDE 0.9% 500M|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.25||||0.25||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|NON CONTRACTED|COMMERCIAL OTHER 1|0.25||||||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Medicare|MEDICARE PART B ONLY IP|0.25||||||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Medicare|MEDICARE ACUTE|0.25||||0.25||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Rusk State Hospital|RUSK STATE HOSP|0.25||||||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Tricare|TRICARE EAST REGION|||||0.25||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.25||||0.25||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Managed Medicare|HEALTHSPRING MA|0.25||||||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Managed Medicaid|MEDICAID SUPERIOR|0.25||||0.25||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Managed Medicaid|MEDICAID AMERIGROUP|0.25||||0.25||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.25||||0.25||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||0.25||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Medicaid|MEDICAID|0.25||||0.25||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|0.25||||0.25||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Medicaid|COUNTY INDIGENT HEALTH OTHER|0.25||||||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Humana Medicare Advantage|HUMANA MA|0.25||||0.25||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Cigna|CIGNA|||||0.25||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|0.25||||0.25||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.25||||0.25||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.25||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.25||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Aenta Medicare Advantage|AETNA MEDICARE MA|0.25||||||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Blue Cross HMO Specialty|BCBSTX HMO|0.25||||0.25||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|0.25||||||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Blue Cross PPO Specialty|BCBSTX PPO|0.25||||0.25||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|United Medicare Advantage|AARP UHC WEST COMPLETE MA|0.25||||0.25||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.25||||0.25||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|United Medicare Advantage|UHC MEDICARE GOLD MA|0.25||||0.25||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|United Healthcare|UNITED HEALTHCARE OTHER|0.25||||||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|United Healthcare|UNITED HEALTHCARE|0.25||||||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|United Healthcare|UMR UNITED MEDICAL RESOURCES|||||0.25||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|United Healthcare|UNITED HEALTHCARE|||||0.25||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|United Healthcare|TML GROUP BENEFITS|0.25||||||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Veterans Affairs|VETERANS ADMINISTRATION|0.25||||||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Workers Compensation|WORKERS COMPENSATION OTHER|0.25||||||| J7050|ERX|0258|SODIUM CHLORIDE 0.9% 250M|Workers Compensation|UT EMPLOYEE INJURY|0.25||||||| 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||||117.50||| J7060|ERX|0258|DEXTROSE 5%-WATER 250ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|160.50||||160.50||| J7060|ERX|0258|DEXTROSE 5%-WATER 100ML|United Medicare Advantage|UHC MEDICARE GOLD MA|117.50||||||| J7060|ERX|0258|DEXTROSE 5%-WATER 250ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|117.50||||160.50||| J7060|ERX|0258|DEXTROSE 5%-WATER 250ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|160.50||||||| J7060|ERX|0258|DEXTROSE 5%-WATER 250ML|Aenta Medicare Advantage|AETNA MEDICARE MA|160.50||||||| J7060|ERX|0258|DEXTROSE 5%-WATER 250ML|Blue Cross HMO Specialty|BCBSTX HMO|160.50||||160.50||| J7060|ERX|0258|DEXTROSE 5%-WATER 100ML|Blue Cross PPO Specialty|BCBSTX PPO|117.50||||||| J7060|ERX|0258|DEXTROSE 5%-WATER 250ML|Blue Cross PPO Specialty|BCBSTX OTHER|||||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|Aetna|AETNA PPO|160.50||||||| J7060|ERX|0258|DEXTROSE 5%-WATER 250ML|Workers Compensation|WORKERS COMPENSATION OTHER|||||160.50||| J7060|ERX|0258|DEXTROSE 5%-WATER 250ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|160.50||||||| J7060|ERX|0258|DEXTROSE 5%-WATER 500ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||165.25||| J7060|ERX|0258|DEXTROSE 5%-WATER 250ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||160.50||| J7060|ERX|0258|DEXTROSE 5%-WATER 250ML|Medicaid|MEDICAID|||||160.50||| J7060|ERX|0258|DEXTROSE 5%-WATER 500ML|Managed Medicaid|MEDICAID AMERIGROUP|117.50||||165.25||| J7060|ERX|0258|DEXTROSE 5%-WATER 250ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|160.50||||160.50||| J7060|ERX|0258|DEXTROSE 5%-WATER 100ML|Managed Medicaid|MEDICAID SUPERIOR|117.50||||||| 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|117.50||||160.50||| J7060|ERX|0258|DEXTROSE 5%-WATER 250ML|NON CONTRACTED|COMMERCIAL OTHER 1|160.50||||||| J7060|ERX|0258|DEXTROSE 5%-WATER 100ML|NON CONTRACTED|COMMERCIAL OTHER 1|117.50||||||| J7060|ERX|0258|DEXTROSE 5%-WATER 250ML|Medicare|MEDICARE ACUTE|160.50||||160.50||| J7060|ERX|0258|DEXTROSE 5%-WATER 250ML|Medicare|MEDICARE ACUTE|117.50||||160.50||| J7060|ERX|0258|DEXTROSE 5%-WATER 250ML|Rusk State Hospital|RUSK STATE HOSP|160.50||||||| J7060|ERX|0258|DEXTROSE 5%-WATER 100ML|Rusk State Hospital|RUSK STATE HOSP|117.50||||||| J7060|ERX|0258|DEXTROSE 5%-WATER 250ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|160.50||||160.50||| J7060|ERX|0258|DEXTROSE 5%-WATER 250ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|117.50||||160.50||| J7070|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|NON CONTRACTED|COMMERCIAL OTHER 1|122.25||||||| J7070|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Medicare|MEDICARE ACUTE|162.25||||172.75||| J7070|ERX|0258|DEXTROSE 5%-WATER 1000ML|Medicare|MEDICARE ACUTE|1.76||||178.50||| J7070|ERX|0258|DEXTROSE 5%-NS 1000ML|Medicare|MEDICARE ACUTE|188.50||||178.50||| J7070|ERX|0258|DEXTROSE 5%-LR 1000ML|Medicare|MEDICARE ACUTE|172.75||||178.50||| J7070|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Medicare|MEDICARE ACUTE|122.25||||122.25||| J7070|ERX|0258|DEXTROSE 5%-WATER 1000ML|Rusk State Hospital|RUSK STATE HOSP|1.76||||||| J7070|ERX|0258|DEXTROSE 5%-NS 1000ML|Rusk State Hospital|RUSK STATE HOSP|188.50||||||| J7070|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Medicaid Out of State|MEDICAID OUT OF STATE OTHER|||||172.75||| J7070|ERX|0258|DEXTROSE 5%-WATER 1000ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|172.75||||1.76||| J7070|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|UTMB|UTMB CORRECTIONAL MANAGED CARE|122.25||||122.25||| J7070|ERX|0258|DEXTROSE 5%-NS 1000ML|Managed Medicare|HEALTHSPRING MA|188.50||||||| J7070|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Medicaid|MEDICAID TEXAS CHILDRENS|||||172.75||| J7070|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Medicaid|MEDICAID|178.50||||172.75||| J7070|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Medicaid|SUPERIOR HEALTHPLAN CHIP|122.25||||||| J7070|ERX|0258|DEXTROSE 5%-NS 1000ML|Managed Medicaid|MEDICAID SUPERIOR|172.75||||188.50||| J7070|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|122.25||||172.75||| J7070|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Managed Medicaid|MEDICAID SUPERIOR|122.25||||122.25||| 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 UNITED HEALTHCARE|122.25||||122.25||| J7070|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Managed Medicaid|MEDICAID AMERIGROUP|122.25||||122.25||| J7070|ERX|0258|DEXTROSE 5%-WATER 1000ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|188.50||||1.76||| J7070|ERX|0258|DEXTROSE 5%-LR 1000ML|Humana Medicare Advantage|HUMANA MA|178.50||||172.75||| J7070|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Humana Medicare Advantage|HUMANA MA|172.75||||172.75||| J7070|ERX|0258|DEXTROSE 5%-WATER 1000ML|Humana Medicare Advantage|HUMANA MA|1.76||||172.75||| J7070|ERX|0258|DEXTROSE 5%-NS 1000ML|Humana Medicare Advantage|HUMANA MA|188.50||||172.75||| J7070|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Cigna|CIGNA|||||172.75||| J7070|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Humana Medicare Advantage|HUMANA MA|122.25||||122.25||| J7070|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|172.75||||172.75||| J7070|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|122.25||||172.75||| J7070|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|172.75||||||| J7070|ERX|0258|DEXTROSE 5%-NS 1000ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|188.50||||||| J7070|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Managed Medicaid|MEDICAID AMERIGROUP|172.75||||172.75||| J7070|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|172.75||||||| J7070|ERX|0258|DEXTROSE 5%-WATER 1000ML|Aenta Medicare Advantage|AETNA MEDICARE MA|1.76||||||| J7070|ERX|0258|DEXTROSE 5%-NS 1000ML|Aenta Medicare Advantage|AETNA MEDICARE MA|188.50||||||| J7070|ERX|0258|DEXTROSE 5%-LR 1000ML|Aenta Medicare Advantage|AETNA MEDICARE MA|178.50||||||| J7070|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Aenta Medicare Advantage|AETNA MEDICARE MA|172.75||||||| J7070|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Aenta Medicare Advantage|AETNA MEDICARE MA|122.25||||||| J7070|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Medicaid|MEDICAID|178.50||||122.25||| J7070|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Blue Cross HMO Specialty|BCBSTX HMO|172.75||||122.25||| J7070|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Blue Cross HMO Specialty|BCBSTX HMO|188.50||||172.75||| J7070|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Managed Medicare|HEALTHSPRING MA|122.25||||||| J7070|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Aetna|AETNA PPO|122.25||||||| J7070|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Blue Cross PPO Specialty|BCBSTX PPO|122.25||||122.25||| J7070|ERX|0258|DEXTROSE 5%-LR 1000ML|Blue Cross PPO Specialty|BCBSTX PPO|1.76||||178.50||| J7070|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Blue Cross PPO Specialty|BCBSTX PPO|172.75||||172.75||| J7070|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Rusk State Hospital|RUSK STATE HOSP|122.25||||||| J7070|ERX|0258|DEXTROSE 5%-WATER 1000ML|Blue Cross PPO Specialty|BCBSTX PPO|1.76||||1.76||| J7070|ERX|0258|DEXTROSE 5%-NS 1000ML|United Medicare Advantage|UHC MEDICARE GOLD MA|188.50||||||| J7070|ERX|0258|DEXTROSE 5%-NS 1000ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|188.50||||172.75||| J7070|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|172.75||||172.75||| J7070|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|United Medicare Advantage|UHC MEDICARE GOLD MA|172.75||||||| J7070|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|172.75||||172.75||| J7070|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|United Medicare Advantage|UHC MEDICARE GOLD MA|122.25||||||| J7070|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|United Medicare Advantage|AARP UHC WEST COMPLETE MA|122.25||||122.25||| J7070|ERX|0258|DEXTROSE 5%-WATER 1000ML|NON CONTRACTED|COMMERCIAL OTHER 1|1.76||||||| J7070|ERX|0258|DEXTROSE 5%-WATER 1000ML|United Medicare Advantage|AARP UHC WEST COMPLETE MA|1.76||||172.75||| J7070|ERX|0258|DEXTROSE 5%-LR 1000ML|United Medicare Advantage|UHC MEDICARE GOLD MA|178.50||||||| J7070|ERX|0258|DEXTROSE 5%-NS 1000ML|United Healthcare|TML GROUP BENEFITS|188.50||||||| J7070|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|United Healthcare|UMR UNITED MEDICAL RESOURCES|172.75||||122.25||| J7070|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|United Healthcare|UNITED HEALTHCARE|||||172.75||| J7070|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|United Healthcare|UMR UNITED MEDICAL RESOURCES|172.75||||172.75||| J7070|ERX|0258|DEXTROSE 5%-NS 1000ML|United Healthcare|UNITED HEALTHCARE|188.50||||||| J7070|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|United Healthcare|UNITED HEALTHCARE|122.25||||||| J7070|ERX|0258|DEXTROSE 5%-1/2 NS 1000ML|Veterans Affairs|VETERANS ADMINISTRATION|172.75||||||| J7070|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Workers Compensation|WORKERS COMPENSATION OTHER|122.25||||||| J7070|ERX|0258|DEX 5%-1/2NS KCL 20 MEQ 1|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|||||122.25||| 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|United Healthcare|UNITED HEALTHCARE|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|United Healthcare|UNITED HEALTHCARE OTHER|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|United Healthcare|UMR UNITED MEDICAL RESOURCES|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|Access Direct Platinum|HEALTHFIRST TPA UMR|||||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|Aenta Medicare Advantage|AETNA MEDICARE MA|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|Aetna|AETNA PPO|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Aetna|AETNA OTHER|||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Blue Cross PPO Specialty|BCBSTX OTHER|||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Blue Cross PPO Specialty|BCBSTX PPO|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Humana Medicare Advantage|HUMANA MA|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Brinson Benefits|THE HEALTH PLAN SMITH CO|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Cigna|CIGNA|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Cigna|CIGNA|173.25||||||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Cigna|CIGNA|||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Managed Medicare|HEALTHSPRING MA|173.25||||||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Managed Medicare|BCBS MEDICARE PPO MA|||||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|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Medicaid|MOLINA HEALTHCARE OF TEXAS|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Medicaid|SUPERIOR HEALTHPLAN CHIP|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Medicaid|MEDICAID|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|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Managed Medicaid|MEDICAID AMERIGROUP|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|NON CONTRACTED|COMMERCIAL OTHER 2|173.25||||||| J7120|ERX|0258|LACTATED RINGERS 1000ML|NON CONTRACTED|COMMERCIAL OTHER 1|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Medicare|MEDICARE ACUTE|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Rusk State Hospital|RUSK STATE HOSP|||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Texas Workforce Commission|DEPT OF ASSIST AND REHAB SRVCS|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|Tricare|TRICARE EAST REGION|173.25||||173.25||| J7120|ERX|0258|LACTATED RINGERS 1000ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|173.25||||173.25||| J9312|ERX|0636|RITUXIMAB 100MG/10ML|Blue Cross PPO Specialty|BCBSTX PPO|||||357.02||| L0172|EAP|0274|COLLAR, CERVICAL PHIL.174|Medicare|MEDICARE ACUTE|240.25||||222.50||| L0172|EAP|0274|COLLAR,CERVICAL PHILADELP|Medicare|MEDICARE ACUTE|240.25||||240.25||| L0172|EAP|0274|COLLAR,CERVICAL PHILADELP|Rusk State Hospital|RUSK STATE HOSP|||||240.25||| L0172|EAP|0274|COLLAR,CERVICAL PHILADELP|Tricare|TRICARE EAST REGION|||||240.25||| L0172|EAP|0274|COLLAR,CERVICAL PHILADELP|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||240.25||| L0172|EAP|0274|COLLAR, CERVICAL PHIL.174|Managed Medicaid|MEDICAID AMERIGROUP|||||222.50||| L0172|EAP|0274|COLLAR,CERVICAL PHILADELP|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||240.25||| L0172|EAP|0274|COLLAR,CERVICAL PHILADELP|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||240.25||| L0172|EAP|0274|COLLAR, CERVICAL PHIL.174|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||222.50||| L0172|EAP|0274|COLLAR,CERVICAL PHILADELP|Blue Cross HMO Specialty|BCBSTX HMO|||||240.25||| L0172|EAP|0274|COLLAR,CERVICAL PHILADELP|Blue Cross PPO Specialty|BCBSTX PPO|||||240.25||| L0172|EAP|0274|COLLAR, CERVICAL PHIL.174|Blue Cross PPO Specialty|BCBSTX PPO|||||222.50||| L0172|EAP|0274|COLLAR,CERVICAL PHILADELP|Cigna|CIGNA|||||1.11||| L1830|EAP|0274|"IMMOBILIZER,KNEE 19"" CONT"|United Healthcare|UNITED HEALTHCARE|||||357.50||| L1830|EAP|0274|"IMMOBILIZER,KNEE 19"" CONT"|Workers Compensation|WORKERS COMPENSATION OTHER|357.50||||||| L1830|EAP|0274|"IMMOBILIZER,KNEE 19"" CONT"|Workers Compensation|UT EMPLOYEE INJURY|||||357.50||| L1830|EAP|0274|"IMMOBILIZER,KNEE 19"" CONT"|United Medicare Advantage|UHC MEDICARE GOLD MA|||||357.50||| L1830|EAP|0274|"IMMOBILIZER,KNEE 19"" CONT"|Cigna|CIGNA|||||357.50||| L1830|EAP|0274|"IMMOBILIZER,KNEE 24"" CONT"|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||267.25||| 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 PPO|||||267.25||| L1830|EAP|0274|"IMMOBILIZER,KNEE 19"" CONT"|Blue Cross PPO Specialty|BCBSTX PPO|||||357.50||| L1830|EAP|0274|"IMMOBILIZER,KNEE 19"" CONT"|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||357.50||| L1830|EAP|0274|"IMMOBILIZER,KNEE 19"" CONT"|Managed Medicaid|MEDICAID AMERIGROUP|||||357.50||| L1830|EAP|0274|"IMMOBILIZER,KNEE 19"" CONT"|NON CONTRACTED|COMMERCIAL OTHER 1|||||357.50||| L1830|EAP|0274|"IMMOBILIZER,KNEE 19"" CONT"|Medicare|MEDICARE ACUTE|357.50||||357.50||| L1830|EAP|0274|"IMMOBILIZER,KNEE 24"" CONT"|Medicare|MEDICARE ACUTE|357.50||||267.25||| L1830|EAP|0274|"IMMOBILIZER,KNEE 19"" CONT"|Rusk State Hospital|RUSK STATE HOSP|||||357.50||| L3808|EAP|0274|SPLINT WRIST COCKUP L EA|Medicare|MEDICARE ACUTE|||||180.75||| L3808|EAP|0274|SPLINT WRIST COCKUP R EA|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||172.75||| 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 L EA|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||180.75||| 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|Blue Cross HMO Specialty|BCBSTX HMO|||||180.75||| L3808|EAP|0274|SPLINT WRIST COCKUP L EA|Blue Cross PPO Specialty|BCBSTX PPO|||||180.75||| L3808|EAP|0274|SPLINT WRIST COCKUP R EA|Humana Medicare Advantage|HUMANA MA|||||172.75||| L3808|EAP|0274|SPLINT WRIST COCKUP R EA|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||172.75||| L3808|EAP|0274|SPLINT WRIST COCKUP L EA|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||180.75||| P9016|EAP|0381|LEUKOCYTE REDUCED RED BLO|United Medicare Advantage|UHC MEDICARE GOLD MA|8.58||||8.58||| P9016|EAP|0381|LEUKOCYTE REDUCED RED BLO|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|8.58||||8.58||| P9016|EAP|0381|LEUKOCYTE REDUCED RED BLO|United Healthcare|UNITED HEALTHCARE OTHER|8.58||||8.58||| P9016|EAP|0381|LEUKOCYTE REDUCED RED BLO|United Healthcare|UNITED HEALTHCARE|||||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|Blue Cross PPO Specialty|BCBSTX OTHER|||||8.58||| P9016|EAP|0381|LEUKOCYTE REDUCED RED BLO|Humana Medicare Advantage|HUMANA MA|8.58||||8.58||| P9016|EAP|0381|LEUKOCYTE REDUCED RED BLO|Cigna|CIGNA|8.58||||||| 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|United Medicare Advantage|AARP UHC WEST COMPLETE MA|8.58||||||| P9016|EAP|0381|LEUKOCYTE REDUCED RED BLO|Aenta Medicare Advantage|AETNA MEDICARE MA|8.58||||||| P9016|EAP|0381|LEUKOCYTE REDUCED RED BLO|Blue Cross HMO Specialty|BCBSTX HMO|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 UNITED HEALTHCARE|8.58||||||| P9016|EAP|0381|LEUKOCYTE REDUCED RED BLO|Managed Medicaid|MEDICAID SUPERIOR|8.58||||8.58||| P9016|EAP|0381|LEUKOCYTE REDUCED RED BLO|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|8.58||||8.58||| P9016|EAP|0381|LEUKOCYTE REDUCED RED BLO|Managed Medicaid|MEDICAID AMERIGROUP|8.58||||||| P9016|EAP|0381|LEUKOCYTE REDUCED RED BLO|Medicaid|MEDICAID|8.58||||8.58||| P9016|EAP|0381|LEUKOCYTE REDUCED RED BLO|NON CONTRACTED|COMMERCIAL OTHER 1|8.58||||8.58||| 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||| P9017|EAP|0390|PLASMA FRESH FROZEN PER U|Medicare|MEDICARE ACUTE|20.82||||||| P9017|EAP|0390|PLASMA FRESH FROZEN PER U|UTMB|UTMB CORRECTIONAL MANAGED CARE|20.82||||||| P9017|EAP|0390|PLASMA FRESH FROZEN PER U|Managed Medicaid|MEDICAID UNITED HEALTHCARE|20.82||||||| P9017|EAP|0390|PLASMA FRESH FROZEN PER U|Managed Medicaid|MEDICAID SUPERIOR|20.82||||20.82||| P9017|EAP|0390|PLASMA FRESH FROZEN PER U|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|20.82||||||| P9017|EAP|0390|PLASMA FRESH FROZEN PER U|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|20.82||||||| P9017|EAP|0390|PLASMA FRESH FROZEN PER U|Humana Medicare Advantage|HUMANA MA|20.82||||||| P9017|EAP|0390|PLASMA FRESH FROZEN PER U|United Healthcare|UNITED HEALTHCARE OTHER|20.82||||||| P9019|EAP|0390|PLATELETS SINGLE DONOR PH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||23.59||| P9019|EAP|0390|PLATELETS SINGLE DONOR PH|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|23.59||||||| P9035|EAP|0390||Medicare|MEDICARE ACUTE|23.59||||||| P9035|EAP|0390||UTMB|UTMB CORRECTIONAL MANAGED CARE|23.59||||||| P9035|EAP|0390||Managed Medicaid|MEDICAID SUPERIOR|23.59||||||| P9035|EAP|0390||Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|23.59||||||| P9035|EAP|0390||United Healthcare|UNITED HEALTHCARE OTHER|23.59||||||| P9035|EAP|0390||Humana Medicare Advantage|HUMANA MA|23.59||||||| P9035|EAP|0390||Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|23.59||||23.59||| P9035|EAP|0390||Aenta Medicare Advantage|AETNA MEDICARE MA|23.59||||||| P9038|EAP|0381|RED BLOOD CELLS IRRADIATE|Medicare|MEDICARE ACUTE|||||7.39||| P9047|ERX|0636|ALBUMIN 25%, 25G/100ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1,155.63||||||| P9047|ERX|0636|ALBUMIN 25%, 25G/100ML|Aenta Medicare Advantage|AETNA MEDICARE MA|1,155.63||||||| P9047|ERX|0636|ALBUMIN 25%, 25G/100ML|Humana Medicare Advantage|HUMANA MA|1,155.63||||||| P9047|ERX|0636|ALBUMIN 25%, 25G/100ML|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|1,155.63||||||| P9047|ERX|0636|ALBUMIN 25%, 25G/100ML|Managed Medicaid|MEDICAID SUPERIOR|1,155.63||||||| P9047|ERX|0636|ALBUMIN 25%, 25G/100ML|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1,155.63||||||| P9047|ERX|0636|ALBUMIN 25%, 25G/100ML|Medicaid|MEDICAID|1,155.63||||||| P9047|ERX|0636|ALBUMIN 25%, 25G/100ML|Medicare|MEDICARE ACUTE|1,155.63||||||| P9612|EAP|0300|CATH URETHRA NON-INDWELLI|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.77||| P9612|EAP|0300|CATH URETHRA NON-INDWELLI|Medicare|MEDICARE ACUTE|0.77||||||| P9612|EAP|0300|CATH URETHRA NON-INDWELLI|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.77||| P9612|EAP|0300|CATH URETHRA NON-INDWELLI|Workers Compensation|WORKERS COMPENSATION OTHER|||||0.77||| P9612|EAP|0300|CATH URETHRA NON-INDWELLI|Humana Medicare Advantage|HUMANA MA|0.77||||||| Q2009|ERX|0636|FOSPHENYTOIN 100MG/2ML VI|Blue Cross HMO Specialty|BCBSTX HMO|33.60||||||| Q2009|ERX|0636|FOSPHENYTOIN 500MG/10ML V|Blue Cross HMO Specialty|BCBSTX HMO|1.16||||||| Q2009|ERX|0636|FOSPHENYTOIN 500MG/10ML V|Blue Cross PPO Specialty|BCBSTX PPO|||||1.16||| Q2009|ERX|0636|FOSPHENYTOIN 500MG/10ML V|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||1.16||| Q2009|ERX|0636|FOSPHENYTOIN 500MG/10ML V|UTMB|UTMB CORRECTIONAL MANAGED CARE|1.16||||1.16||| Q2009|ERX|0636|FOSPHENYTOIN 500MG/10ML V|Medicare|MEDICARE ACUTE|||||1.16||| Q5104|ERX|0636|RENFLEXIS 100 MG VIAL|Medicare|MEDICARE ACUTE|||||286.28||| Q9957|EAP|0636|DEFINITY 1.3ML VIAL|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||4.35||| Q9957|EAP|0636|DEFINITY 1.3ML VIAL|Humana Medicare Advantage|HUMANA MA|4.35||||||| Q9957|EAP|0636|DEFINITY 1.3ML VIAL|Medicare|MEDICARE ACUTE|4.35||||||| Q9967|EAP|0255|ISOVUE M-300 PER ML|Managed Medicaid|MEDICAID SUPERIOR|0.75||||2.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|Managed Medicare|HEALTHSPRING MA|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 370 PER ML|Managed Medicare|HEALTHSPRING MA|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 370 PER ML|Managed Medicaid|MEDICAID UNITED HEALTHCARE|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||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 AMERIGROUP|0.75||||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|Managed Medicaid|MEDICAID SUPERIOR|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|Medicaid|MOLINA HEALTHCARE OF TEXAS|0.75||||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|SUPERIOR HEALTHPLAN CHIP|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 370 PER ML|Medicaid|MEDICAID|0.75||||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 1|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|Medicare|MEDICARE ACUTE|0.75||||0.75||| Q9967|EAP|0255|ISOVUE M-300 PER ML|Medicare|MEDICARE ACUTE|0.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 PER ML|Rusk State Hospital|RUSK STATE HOSP|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|Tricare|TRICARE EAST REGION|||||0.75||| Q9967|EAP|0255|ISOVUE 370 PER ML|Tricare|TRICARE EAST REGION|||||0.75||| Q9967|EAP|0255|ISOVUE 370 PER ML|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.75||||0.75||| Q9967|EAP|0255|ISOVUE M-300 PER ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 PER ML|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|0.75||||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 M-300 PER ML|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|0.75||||2.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|Access Direct Platinum|HEALTHFIRST TPA OTHER 1|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 370 PER ML|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|0.75||||0.75||| 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 M-300 PER ML|Blue Cross HMO Specialty|BCBSTX HMO|0.75||||2.75||| 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|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 300 MG/ML IODINE P|Aetna|AETNA OTHER|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|Aetna|AETNA PPO|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|Rusk State Hospital|RUSK STATE HOSP|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 370 PER ML|Medicare|MEDICARE ACUTE|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 370 PER ML|Aetna|AETNA PPO|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|Blue Cross PPO Specialty|BCBSTX OTHER|0.75||||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 M-300 PER ML|Humana Medicare Advantage|HUMANA MA|0.75||||2.75||| Q9967|EAP|0255|ISOVUE 370 PER ML|Humana Medicare Advantage|HUMANA MA|0.75||||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|Cigna|CIGNA|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|Cigna|CIGNA|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|Cigna|CIGNA|||||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|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|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|Veterans Affairs|VETERANS ADMINISTRATION|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 300 MG/ML IODINE P|Workers Compensation|WORKERS COMPENSATION OTHER|||||0.75||| Q9967|EAP|0255|ISOVUE 370 PER ML|United Healthcare|UNITED HEALTHCARE OTHER|||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|Managed Medicare|BCBS MEDICARE PPO MA|||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|United Healthcare|TML GROUP BENEFITS|||||0.75||| Q9967|EAP|0255|ISOVUE 370 PER ML|United Healthcare|UMR UNITED MEDICAL RESOURCES|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|United Healthcare|UNITED HEALTHCARE OTHER|||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|United Healthcare|UNITED HEALTHCARE|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 370 PER ML|United Healthcare|UNITED HEALTHCARE|0.75||||0.75||| Q9967|EAP|0255|ISOVUE 300 MG/ML IODINE P|United Healthcare|UMR UNITED MEDICAL RESOURCES|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 370 PER ML|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP 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|AARP UHC WEST COMPLETE MA|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|United Medicare Advantage|UHC MEDICARE GOLD MA|0.75||||0.75||| Q9969|EAP|0343|NON HEU TC99 ADD ON DOSE|United Medicare Advantage|UHC MEDICARE SOLUTIONS MA|||||0.01||| Q9969|EAP|0343|NON HEU TC99 ADD ON DOSE|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||0.01||| Q9969|EAP|0343|NON HEU TC99 ADD ON DOSE|United Medicare Advantage|UHC MEDICARE GOLD MA|||||0.01||| Q9969|EAP|0343|NON HEU TC99 ADD ON DOSE|United Healthcare|UNITED HEALTHCARE|||||0.01||| Q9969|EAP|0343|NON HEU TC99 ADD ON DOSE|Blue Cross PPO Specialty|BCBSTX OTHER|||||0.01||| Q9969|EAP|0343|NON HEU TC99 ADD ON DOSE|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||0.01||| Q9969|EAP|0343|NON HEU TC99 ADD ON DOSE|Humana Medicare Advantage|HUMANA MA|0.01||||0.01||| Q9969|EAP|0343|NON HEU TC99 ADD ON DOSE|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|||||0.01||| Q9969|EAP|0343|NON HEU TC99 ADD ON DOSE|Aenta Medicare Advantage|AETNA MEDICARE MA|0.01||||0.01||| Q9969|EAP|0343|NON HEU TC99 ADD ON DOSE|Access Direct Platinum|HEALTHFIRST TPA UTH UMR|||||0.01||| Q9969|EAP|0343|NON HEU TC99 ADD ON DOSE|Cigna|CIGNA|||||0.01||| Q9969|EAP|0343|NON HEU TC99 ADD ON DOSE|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||0.01||| Q9969|EAP|0343|NON HEU TC99 ADD ON DOSE|Blue Cross HMO Specialty|BCBSTX HMO|||||0.01||| Q9969|EAP|0343|NON HEU TC99 ADD ON DOSE|Aetna|AETNA PPO|||||0.01||| Q9969|EAP|0343|NON HEU TC99 ADD ON DOSE|Aetna|AETNA OTHER|||||0.01||| Q9969|EAP|0343|NON HEU TC99 ADD ON DOSE|Blue Cross PPO Specialty|BCBSTX PPO|||||0.01||| Q9969|EAP|0343|NON HEU TC99 ADD ON DOSE|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|0.01||||0.01||| Q9969|EAP|0343|NON HEU TC99 ADD ON DOSE|NON CONTRACTED|COMMERCIAL OTHER 2|||||0.01||| Q9969|EAP|0343|NON HEU TC99 ADD ON DOSE|NON CONTRACTED|COMMERCIAL OTHER 1|||||0.01||| Q9969|EAP|0343|NON HEU TC99 ADD ON DOSE|Tricare|TRICARE EAST REGION|||||0.01||| Q9969|EAP|0343|NON HEU TC99 ADD ON DOSE|Medicare|MEDICARE ACUTE|0.01||||0.01||| Q9969|EAP|0343|NON HEU TC99 ADD ON DOSE|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||0.01||| Q9969|EAP|0343|NON HEU TC99 ADD ON DOSE|Medicaid|MOLINA HEALTHCARE OF TEXAS|||||0.01||| Q9969|EAP|0343|NON HEU TC99 ADD ON DOSE|UTMB|UTMB CORRECTIONAL MANAGED CARE|0.01||||||| Q9969|EAP|0343|NON HEU TC99 ADD ON DOSE|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||0.01||| Q9969|EAP|0343|NON HEU TC99 ADD ON DOSE|Managed Medicare|HEALTHSPRING MA|||||0.01||| Q9969|EAP|0343|NON HEU TC99 ADD ON DOSE|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||0.01||| Q9969|EAP|0343|NON HEU TC99 ADD ON DOSE|Managed Medicaid|MEDICAID SUPERIOR|||||0.01||| Q9969|EAP|0343|NON HEU TC99 ADD ON DOSE|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|||||0.01||| Q9969|EAP|0343|NON HEU TC99 ADD ON DOSE|Managed Medicaid|MEDICAID AMERIGROUP|||||0.01||| U0001|EAP|0300|COVID - 19PCR|Managed Medicaid|MEDICAID UNITED HEALTHCARE|||||1.80||| U0001|EAP|0300|COVID - 19PCR|Managed Medicaid|MEDICAID SUPERIOR|||||1.80||| U0001|EAP|0300|COVID - 19PCR|Managed Medicaid|MEDICAID AMERIGROUP|||||1.80||| U0001|EAP|0300|COVID - 19PCR|Medicaid|MEDICAID|||||1.80||| U0001|EAP|0300|COVID - 19PCR|Medicaid|SUPERIOR HEALTHPLAN CHIP|||||1.80||| U0001|EAP|0300|COVID - 19PCR|Medicaid|MEDICAID HMO|||||1.80||| U0001|EAP|0300|COVID - 19PCR|Medicaid|MEDICAID TEXAS CHILDRENS|||||1.80||| U0001|EAP|0300|COVID - 19PCR|Medicare|MEDICARE ACUTE|1.80||||1.80||| U0001|EAP|0300|COVID - 19PCR|Tricare|TRICARE EAST REGION|||||1.80||| U0001|EAP|0300|COVID - 19PCR|UTMB|UTMB CORRECTIONAL MANAGED CARE|||||1.80||| U0001|EAP|0300|COVID - 19PCR|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||1.80||| U0001|EAP|0300|COVID - 19PCR|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.80||||||| U0001|EAP|0300|COVID - 19PCR|Blue Cross HMO Specialty|BCBSTX HMO|||||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|Cigna|CIGNA|||||1.80||| U0001|EAP|0300|COVID - 19PCR|Blue Cross PPO Specialty|BCBSTX PPO|||||1.80||| U0001|EAP|0300|COVID - 19PCR|Blue Cross PPO Specialty|BCBSTX OTHER|1.80||||||| U0001|EAP|0300|COVID - 19PCR|United Healthcare|UNITED HEALTHCARE|||||1.80||| U0001|EAP|0300|COVID - 19PCR|United Medicare Advantage|UHC MEDICARE GOLD MA|||||1.80||| U0001|EAP|0300|COVID - 19PCR|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|||||1.80||| U0001|EAP|0300|COVID - 19PCR|United Medicare Advantage|AARP UHC WEST COMPLETE MA|||||1.80||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|United Healthcare|UNITED HEALTHCARE|1.54||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|United Healthcare|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|United Healthcare|UNITED HEALTHCARE|||||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 Medicare Advantage|UHC MEDICARE GOLD MA|||||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|Workers Compensation|UT EMPLOYEE INJURY|||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Workers Compensation|STATE OFFICE OF RISK MANAGEMNT|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|Blue Cross PPO Specialty|BCBSTX OTHER|1.54||||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|Cigna|CIGNA|||||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||| 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 UMR|||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|1.54||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Aenta Medicare Advantage|AETNA MEDICARE MA|1.54||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Blue Cross HMO Specialty|BCBSTX HMO|||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Aetna|ZZZZZ AETNA|||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Blue Cross PPO Specialty|BCBSTX PPO|||||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|Aetna|AETNA OTHER|||||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|Rusk State Hospital|RUSK STATE HOSP|1.54||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Workers Compensation|WORKERS COMPENSATION OTHER|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|Medicare|MEDICARE ACUTE|1.54||||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|Tricare|TRICARE FOR LIFE|||||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|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Managed Medicare|HEALTHSPRING MA|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||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|1.54||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Managed Medicaid|MEDICAID AMERIGROUP|||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Medicaid|SUPERIOR HEALTHPLAN CHIP|1.54||||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|Medicaid|MEDICAID TEXAS CHILDRENS|||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Medicaid|MEDICAID PCCM|||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Medicaid|MEDICAID HMO|||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Medicaid|MEDICAID|1.54||||1.54||| U0002|EAP|0300|COVID-19 LAB TEST NON-CDC|Medicaid|COUNTY INDIGENT HEALTH OTHER|||||1.54||| U0003|EAP|0300|COVID-19 TO UT NORTH|Managed Medicare|MEDICARE ADVANTAGE OTHER MA|114.40||||114.40||| U0003|EAP|0300|COVID-19 TO UT NORTH|Managed Medicaid|MEDICAID UNITED HEALTHCARE|114.40||||114.40||| U0003|EAP|0300|COVID-19 TO UT NORTH|Managed Medicaid|MEDICAID SUPERIOR|114.40||||114.40||| U0003|EAP|0300|COVID-19 TO UT NORTH|Managed Medicaid|MEDICAID AMERIGROUP|||||114.40||| U0003|EAP|0300|COVID-19 TO UT NORTH|Medicaid|SUPERIOR HEALTHPLAN CHIP|114.40||||||| U0003|EAP|0300|COVID-19 TO UT NORTH|Medicaid|MEDICAID|114.40||||||| U0003|EAP|0300|COVID-19 TO UT NORTH|Medicare|MEDICARE ACUTE|114.40||||114.40||| U0003|EAP|0300|COVID-19 TO UT NORTH|Rusk State Hospital|RUSK STATE HOSP|114.40||||114.40||| U0003|EAP|0300|COVID-19 TO UT NORTH|UTMB|UTMB CORRECTIONAL MANAGED CARE|114.40||||114.40||| U0003|EAP|0300|COVID-19 TO UT NORTH|Access Direct Platinum|HEALTHFIRST UHSS UT HLTH|||||114.40||| U0003|EAP|0300|COVID-19 TO UT NORTH|Blue Cross Advantage HMO|BCBSTX HMO BLUE ADVANTAGE|114.40||||||| U0003|EAP|0300|COVID-19 TO UT NORTH|Blue Cross HMO Specialty|BCBSTX HMO|114.40||||114.40||| U0003|EAP|0300|COVID-19 TO UT NORTH|Aetna|AETNA PPO|114.40||||||| U0003|EAP|0300|COVID-19 TO UT NORTH|Blue Cross Traditional Specialty|BCBSTX TRADITIONAL|||||114.40||| U0003|EAP|0300|COVID-19 TO UT NORTH|Managed Medicaid|MEDICAID CIGNA HEALTHSPRING|114.40||||114.40||| U0003|EAP|0300|COVID-19 TO UT NORTH|Blue Cross PPO Specialty|BCBSTX PPO|114.40||||114.40||| U0003|EAP|0300|COVID-19 TO UT NORTH|Humana Medicare Advantage|HUMANA MA|114.40||||114.40||| U0003|EAP|0300|COVID-19 TO UT NORTH|Cigna|CIGNA|114.40||||||| U0003|EAP|0300|COVID-19 TO UT NORTH|United Healthcare|UNITED HEALTHCARE|114.40||||114.40||| U0003|EAP|0300|COVID-19 TO UT NORTH|United Healthcare|UNITED HEALTHCARE|114.40||||||| U0003|EAP|0300|COVID-19 TO UT NORTH|United Healthcare|TML GROUP BENEFITS|114.40||||||| U0003|EAP|0300|COVID-19 TO UT NORTH|United Medicare Advantage|UHC DUAL COMPLETE HMO SNP MA|114.40||||||| U0003|EAP|0300|COVID-19 TO UT NORTH|United Medicare Advantage|AARP UHC WEST COMPLETE MA|114.40||||114.40||| U0003|EAP|0300|COVID-19 TO UT NORTH|United Medicare Advantage|UHC MEDICARE GOLD MA|114.40||||114.40||| U0003|EAP|0300|COVID-19 TO UT NORTH|Veterans Affairs|VETERANS ADMINISTRATION|114.40||||||| U0003|EAP|0300|COVID-19 TO UT NORTH|Workers Compensation|WORKERS COMPENSATION OTHER|114.40|||||||